Please use this form to submit your child for consideration as the Indiana 105 Pledge Kid.

Parent Name (*)

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Email Address (*)

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Phone Number (*)

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Child Name (*)

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All submissions are reviewed, however not all submissions can be accepted. Submitting this form is not a guarantee that you will be selected.

Contact or Upload (*)
Contact Me by PhoneI will upload my MP3
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If you selected the contact me by phone, please put what days and times you are available.

Best Time to Contact You (*)

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Upload your MP3

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Human Verfication
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Submit