Night To Shine - Guest Registration

Name Name First Last
Name as you would like it to appear on nametag:
DOB:
Gender:

Gender: Male Female
Address Address
Street Address City State / Province / Region Postal / Zip Code
Email
Phone Phone - ### - ### ####
Fun Fact About You:
Emergency Contact during event (will be listed on guest's nametag):
Emergency Contact Phone (will be listed on guest's nametag):
Will need medication administered during event:

Will need medication administered during event: Yes No
Please note that the church, their staff, and volunteers are not responsible for administering medication to guests during the Night to Shine event. If medication is required during the event, a parent or caretaker MUST be available to administer the medication.
Will guest be dropped off and picked up by parent/caretaker?

Will guest be dropped off and picked up by parent/caretaker? Yes No
Will guest be taking public transportation to and from event?

Will guest be taking public transportation to and from event? Yes No
Will guest be attending as a part of a group that will provide transportation?

Will guest be attending as a part of a group that will provide transportation? Yes No
We would love to make your Night to Shine experience the best it can possibly be! If you are comfortable sharing, please answer the following optional items, that apply, in order to help us offer the best support we can:
Health Concerns:
Mobility Needs:
Communication Needs:
Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.):
Allergies:

(Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.)
Food Needs: (Food cut-up or pureed, gluten free, dairy free, nut free, etc):
Additional Notes/Concerns You Would Like Us To Be Aware Of:
Caretaker Information
Caretaker Name(s):
Caretaker Phone:
Caretaker will be...

Caretaker will be... Dropping Guest off Enjoying Respite Room
Caretaker relationship to guest:
If enjoying Respite Room, please list caretakers:
The Respite Room is a private area where caretakers of guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event.
Care Provider Agency Information - If Applicable
Care Provider Agency:

(If attending as part of a group, please include agency or company name)
Care Provider Agency Phone:
Agency Chaperone (if applicable):
Agency Chaperone Cell Phone:

(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency. If Chaperone remains with guest(s), a current background check will be required.)
Additional Notes or Concerns:

Night To Shine - Guest Registration

Night To Shine - Guest Registration

Please note that the church, their staff, and volunteers are not responsible for administering medication to guests during the Night to Shine event. If medication is required during the event, a parent or caretaker MUST be available to administer the medication.

We would love to make your Night to Shine experience the best it can possibly be! If you are comfortable sharing, please answer the following optional items, that apply, in order to help us offer the best support we can:

Caretaker Information

The Respite Room is a private area where caretakers of guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event.

Care Provider Agency Information - If Applicable