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Section I: The Basics
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1. First Name:
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Middle Name: |
Last Name: |
| 2. Have you ever formally or
otherwise changed your name? If so, what other names have you used? |
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3. Home Street Address:
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| 4. City: |
State: |
ZIP Code:
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| 5 Phone (Work): |
Phone (Home): |
Cellular (If Applicable):
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6. Email:
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7. Age (As of Today):
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Date of Birth: |
Gender: 1. Male
2. Female
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| 8. Height: |
Weight:
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| Hair Color: |
Eye Color:
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9. Are you a legal resident
of the United States?
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A. Drivers' License #________________________________
B. Social Security # ________________________________ |
| 10 Current Occupation (Please
Include Company, Title and Dates of Employment) |
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| 11 Your Current Marital Status (Circle
One) |
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| Single |
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| Dating |
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| Married |
How Long? _____________________
How Many Times? _______________
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| Not Married, But Living With Significant Other |
How Long? _____________________
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| Separated |
How Long? _____________________
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| Widowed |
How Long? _____________________
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| Divorced |
How Long? _____________________
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| 12 Do You Have Any Children?
If So, please list their name(s) and age(s) |
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| 13. What is The Highest Level
of Education You've Completed (Circle One) |
| High School |
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| Associates College Degree |
Major: ___________________________
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| Bachelor's College Degree |
Major: ___________________________
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| Master's College Degree |
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| Professional or Doctoral Degree
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| 14. What School(s) did you
attend? (Include the City and State and Years of Attendance) |
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| 15. Are You A Member Of Any
Professional Performing Art Union? (i.e. AFTRA or SAG) |
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| 16. Have You Ever Been Arrested?
If So, Tell Us About It? (Include Dates and Jurisdictions) |
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| 17. Have You Ever Been Charged
With A Crime? If So, Tell Us About It (Include Dates and Jurisdictions) |
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| 18. Have You Ever Been Convicted
Of A Crime? Is So, Tell Us About It (Include Dates and Jurisdictions) |
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| 19. Have You Ever Had A Restraining
Order Issued Against You? If So, Tell Us About It? (Include Dates
and Jurisdictions) |
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| 20 Have You Been Involved In
Any Past and/or Pending Litigation? If So, Tell Us About It (Include
Dates and Jurisdictions) |
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| Note: Please give us contact
information for people whom you give us permission to contact as references,
as a means to contact you, or as a means of obtaining additional information
about you. |
| 21 Names and Phone Numbers
of 2 Closest Friends |
1)
2)
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| 22 Names and Phone Numbers
of 2 Nearest Relatives |
1)
2)
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Section II: Family & Lifestyle
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| 23. Why do you feel you should be chosen
to receive the "Mini Makeover?" |
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| 24. If you are selected to
receive the "Mini Makeover," list everything you would like to have
altered? |
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| 25 What areas or parts of your
body are you most unhappy with? Have you always felt that way? If
not, what event changed your image of yourself? |
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| 26. In what ways has your physical
appearance affected your life? |
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| 27. If you were to receive
"The Mini Makeover" in what ways would your life be altered? |
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Section III: Medical
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28. Have You Ever Been Treated
For Any Serious Physical or Mental Illnesses Within The Last Five
(5) Years?
(Circle One) |
Yes
No
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| 29. If You Answered "Yes" In
Question 37, Please Describe In Detail, Indicating Dates, Diagnosis
and Any On-Going Treatments, Prescription Medicines or Difficulties. |
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| 30 Have you ever been treated
for Depression? In your opinion, what triggered your depression? |
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| 31. Are you currently or have
you ever taken anti-depressants? |
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| 32. Please List Any Allergies
You Have (Medications, Food, Hay Fever, Dust, Etc.) And Your Current
Treatment For Them (If Any). |
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| 33. Have You Ever Been Diagnosed
With Alcoholism Or Any Other Drug-Related Addiction? If So, Please
Provide More Details Including How Long You've Been In Recovery, If
That's The Case. |
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| 34. Do you have any sexually
transmitted diseases? If so, please describe: |
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Section IV: Your Chance To Be Creative
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| 35 In A Brief Statement, Tell
Us Why We Should Choose You, Over Anyone Else, To Receive The "Mini
Makeover"? |
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| 36 Besides altering your appearance,
what is your biggest dream? |
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| 37 Have you ever had any type
of plastic or cosmetic surgery? If so, please list specific surgeries
and the reasons for those procedures. |
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| 38 Is there anyone else you
would like to nominate for an Mini Makeover? |
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| 39. Send Us Two Photos: 1)
Face Photo; 2) Full body Photo |
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Section V: Eligibility Requirement, Consents, and Releases
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- You must be a U.S. citizen.
- You or any of your immediate family members (spouse, ex-spouse,
parents, siblings, children) and household members (whether related
or not) may not be employees, officers, directors, representatives
or agents of New Screen Concepts, New Screen Entertainment, Inc.,
Lighthearted Entertainment, Greengrass Productions, Inc., American
Broadcasting Companies, Inc., The Walt Disney Company, known sponsors
of the program or their advertising agencies, any station initially
airing the program, and/or their respective parent, subsidiary,
or affiliated companies, licensees, partners and assigns.
- You must never have been convicted of a felony or misdemeanor,
other than a minor traffic violation, and have never had a restraining
order or other injunctive relief entered against you. There must
not be any outstanding criminal warrants for you.
- You must not have appeared in a prime-time television reality/game
show series or are not involved in the current production of any
such television show.
- If selected as a participant you must execute all waivers and
release agreements required by the producers or by ABC.
- You will need to be available for several days for the Makeover
process, as well as approximately four to seven weeks thereafter
for recoveries (if needed) and participation in a follow-up Makeover
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- You must be in excellent mental and physical health.
- You must be willing to submit medical information to the production
and submit to a medical examination, psychological examination,
and background check.
I hereby acknowledge that:
(i) I have answered the previous questions honestly and accurately;
(ii) I will immediately inform Azcosmeticdocs.com if any information
I have provided becomes false or incomplete;
(iii) if any of the above information is found to be false or incomplete
this will be grounds for dismissal from the participant selection
process, and/or from the program currently entitled "The Mini Makeover",
if selected;
(iv) even if I meet the above eligibility requirements, Azcosmeticdocs.com
has no obligation to interview me, and/or select me as a participant;
(v) even if I am selected as a participant, Azcosmeticdocs.com has
no obligation to conduct the Program or to display it, even if conducted;
(vi) all decisions by Azcosmeticdocs.com concerning selection of the
participants are final and not subject to challenge or appeal; and
(vii) Azcosmeticdocs.com has no obligation to return any materials
submitted by me as part of the application whether or not I am selected
as a participant.
I understand that the Program involves an "Mini Makeover" of the participant
which may include, without limitation, cosmetic and/or plastic surgery
on the participant. I acknowledge that before participating in the
Program, I will consult with my own physician regarding the advisability
from a physical and emotional health perspective of my potential participation
in the Program. I represent that if I proceed with the participant
selection process and am selected to be a participant in the Program,
I know of no reason, following consultation with my own physician,
why I should not participate in the Program.
By submitting this application I hereby consent to the recording,
use and reuse by Azcosmeticdocs.com (collectively "Releasees") of
my voice, before and after photo's, actions, likeness, name, appearance,
biographical material, and any information contained in my application
to be a participant in the Program or in any materials submitted by
me in connection with my application (collectively "Likeness") as
edited, altered, or modified by the Releasees, in any and all media
now known or hereafter devised, in any and all versions, worldwide
in perpetuity, in or in connection with the Program. I agree the Releasees
may use all or any part of my Likeness, and may alter or modify it
regardless of whether or not I am recognizable.
I further agree that Releasees exclusively own all right, title, and
interest (including, without limitation, all copyrights) in and to
any photo's that I have provided in connection with my application
and any other materials that I have provided or may provide in connection
with the Program (the "Materials") including, without limitation,
the right to edit, alter or modify the Materials and to use all or
part of the Materials and my Likeness in any and all media now known
or hereafter devised in any and all versions worldwide, in perpetuity.
I further agree that Releasees may use my Likeness and the Materials
in connection with any promotion, publicity, marketing or advertisement
for the Program. I grant the rights hereunder whether or not I am
selected to participate in the Program in any manner whatsoever. I
agree to release, defend, indemnify and hold harmless Releasees from
any and all claims, actions, lawsuits, liabilities and expenses arising
out of or relating to its recording or use of my Likeness and/or the
Materials. I agree not to make any claim against Releasees as a result
of the recording or use of my Likeness and/or the Materials (including,
without limitation, any claim that such use invades any right of privacy
and/or publicity). I understand that I will not be paid any money
for giving Releasees these rights, or for signing this agreement.
I authorize Azcosmeticdocs.com and its designees to investigate, access
and collect information about me, about any of the statements made
by me in my application, any supporting documents and any other document
that I have signed or do sign in connection with my application to
be selected as a participant in the Program, or any other written
or oral statements I make in connection therewith. I irrevocably authorize
Azcosmeticdocs.com and their respective designees to secure information
about my experiences from my current and former employers, associates,
friends, family members, educational institutions, government agencies,
credit reporting agencies, and any references I have provided, and
I irrevocably authorize such parties to provide information concerning
me. I specifically authorize investigation of my employment record,
medical record, and government records, including but not limited
to my motor vehicle record, civil record, criminal record and consumer
report(s). I agree to execute any authorizations, consents and releases
requested from me by Azcosmeticdocs.com and their respective designees
in connection with their investigation of me. I hereby unconditionally
and irrevocably release and forever discharge all such parties and
persons from any and all liabilities arising out of or in connection
with any such investigation. I agree to undergo to the extent permitted
by law and at the sole discretion of Azcosmeticdocs.com, with no prior
notice to me, any physical and mental examinations requested by Producer
in connection with my possible selection for and participation in
the Program. Such examinations will be conducted by medical personnel
of Azcosmeticdocs.com choosing. I acknowledge that I may not be selected
to participate or my participation may be discontinued at any time
if in the sole and exclusive discretion of Producer and/or its medical
experts the results of such tests indicate that I am not physically
or mentally fit to participate in the Program. I understand and agree
that any physical and/or mental assistance, examinations and/or sessions
I may have with any medical personnel retained by or associated with
the Program, Azcosmeticdocs.com and its affiliates, does not create
a confidential relationship between myself and such medical personnel.
Accordingly, I acknowledge and consent to production doctors, psychologists,
and other medical personnel communicating with Azcosmeticdocs.com
and their designated doctors any diagnoses, prognoses, medical information
and/or opinions regarding me. I hereby waive any physician-patient
privilege I may have or that may arise with any physicians, psychologists,
health care providers (including both physical and mental health care
providers), social workers, health care institutions, insurers, and
other individuals and entities as a result of my participation in
the selection process and/or the Program, and I authorize the release
to Azcosmeticdocs.com and designated doctors of all records and information,
written, verbal, electronic or otherwise, from any of the above persons
and/or entities. I agree to sign any authorizations that Azcosmeticdocs.com
or a health care provider deems necessary to facilitate the release
of such records and information. Without in any way limiting anything
herein, I further hereby release, discharge, relinquish and hold harmless
Releasees from any medical care assistance, treatment or services
provided to me at any time whether such treatment or services are
provided by health care professionals, paramedics, or any other person.
I agree to treat all information and material I receive or acquire
as part of my participation in the participant selection process for
the Program as strictly confidential and to not disclose any such
information to any third party. I specifically acknowledge that the
financial value of the Program to Azcosmeticdocs.com depends on confidentiality
and I agree to be responsible for any and all damages, including consequential
damages that Azcosmeticdocs.com and/or any of the Releasees may suffer
if I breach this confidentiality provision. I agree to release, defend,
indemnify and hold harmless the Releasees and all media and production
companies affiliated with or associated with the production, promotion
and/or broadcast of the Program and their respective owners,employees,
doctors, agents, officers and directors from and against any and all
claims, actions, lawsuits, liabilities and expenses arising from or
relating to: (a) my participation in the Program including, without
limitation, the participant selection process, (b) the use of my Likeness
and/or the Materials, (c) any of my acts or statements relating to
or in connection with the Program; and (d) any breach of my representations
or warranties herein. I understand and agree that all rights under
Section 1542 of the California Civil Code and any similar law of any
state or U.S. territory, any similar federal law, or any similar common
law or principle of similar effect, are hereby expressly waived. I
acknowledge and understand that said section reads as follows: "1542.
Certain claims not affected by general release. A general release
does not extend to claims which the creditor does not know or suspect
to exist in his favor at the tims of executing the release, which
if known by him must have materially affected his settlement with
the debtor." I acknowledge that I may hereafter discover claims in
addition to the ones released herein, and I hereby release Releasees
for any such unknown or unsuspected claims.
I acknowledge that in the event of a breach of this Consent and Release
by Azcosmeticdocs.com or any third party, the damage, if any, caused
me will not be irreparable or otherwise sufficient to entitle me to
seek injunctive or other equitable relief. I acknowledge that my rights
and remedies in any such event will be strictly limited to the right,
if any, to recover damages in an action at law, and I acknowledge
and agree that I will not have the right to rescind this Release or
any of Releasees' rights hereunder, nor the right to enjoin the production,
exhibition or other exploitation of the Program, or any subsidiary
or allied rights with respect thereto, or any other results and proceeds
hereunder. |
| I have read, understand, and agree with the foregoing.
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Signature ___________________________________________________________
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Name (Please print or type) ____________________________________________
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Date: __________________, 2003
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| Thank you for your time and effort in completing
the form.
Deadline: This is a rolling application process. We will
post the deadline on the web site 10 days before we stop accepting
applications.
All Photos will be retained by Azcosmeticdocs.com and become the property
of Azcosmeticdocs.com and will not be returned to you whether or not
you are selected as a contestant. Any expenses you incur during the
application process including postage, shipping, materials preparation
(, photos, etc.) are your sole responsibility. We will not reimburse
you for these expenses. Only one entry per person is allowed. All
decisions of Azcosmeticdocs.com are final and absolute and not subject
to inquiry.
Applications will only be considered if they are complete. Complete
applications consist of the following:
- Completed Application Form
- 2 photos one clear face photo and a full body shot.
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