Date:______________________

Your Information:

First Name:___________________ Last Name:___________________________

Address:_________________________________________________________

Home Phone:______________________________________________________

Cell Phone:________________________________________________________

High School:_______________________________________________________

Activities Involved in:_________________________________________________

_________________________________________________________________

Parents Names:

Mom: ______________________________________

Dad:  ______________________________________

Brief statement from Parent detailing why your son or daughter would be a great
choice to be Senior Rep for Imagery by Rashell:

_______________________________________________________________

_______________________________________________________________

I confirm that this information is true and accurate. Signed:

Senior:_________________________________________

Parent:_________________________________________