Night to Shine 2023

Guest Information

Grace Community Church Warwick | 199 Kings Highway, Warwick, NY, 10990 | Friday, February 10th, | 6pm-9pm
Special Guest Name!*

First NameLast Name
Name or nickname you would like it to appear on the name tag:*
Date of birth*

MonthDayYear
Date
MaleFemale
Address*

Street Address

CityState / Province

Postal / Zip Code
Primary Contact Email*
example@example.com
Primary Contact Phone*
Please enter a valid phone number.
We want to get to know you! Please share with us a fun fact about you!*
Emergency contact phone during event (will be listed on nametag)*

First NameLast Name
Primary Health Concerns*
YesNo
YesNo
If yes, explain:
YesNo
If yes, explain:
List ANY allergies including food, animals, latex, makeup, lotions, pollen or plants, etc.*
Whole diet, no special prepFood cut upFood pureedGluten freeDairy freeNut freeOther
Are there any eating/swallowing issues that we need to be aware of? *
YesNo
NOTE! Please understand that Grace Community, their staff, and volunteers are NOT responsible for administering medication to guests during the Night to Shine event. If medication is required during th event, a parent or cartaker MUST be available to administer the medication.
Transportation and Drop Off
Guest will be dropped off and picked up by a parent/caretakerPublic TransportationGuest will be attending as a part of a group that will provide transportation
Any additional transportation concerns or infomation you would like us to be aware of? *
Parent/Caretaker Information
YesNo
WashingtonvilleNewburghMiddletownWarwickPort JervisDutchess
YesNo
Do you know the Buddy's name?
YesNo
What is the care worker's name? Please let them know they need to fill out a Volunteer for "Night to Shine" application so we can pair them up.
12
Parent/Caretaker Name (1)

First NameLast Name
Parent/Caretaker Phone (1)
Please enter a valid phone number.
Parent/Caretaker Name (2)

First NameLast Name
Parent/Caretaker Phone (2)
Please enter a valid phone number.
Dropping guest off and leavingEnjoying the Respite Room
12
Respite Room - Name 1

First NameLast Name
Respite Room - Name 2

First NameLast Name
Care Provider Agency Information - Complete all areas if applicable
Name of Care Provider Agency
Agency Phone Number
Please enter a valid phone number.
Agency Chaperone (if applicable):

First NameLast Name
Agency Chaperone Cell Phone
Please enter a valid phone number.
Note: Agency chaperone is not requited to stay with guest(s) unless required by Care Provider Agency. If chaperone remains with guest, a background check will be required.
Additional notes/concerns regarding Care Agency or chaperones
Night to Shine Parent/Caretaker Media Rights Release
For the good and valuable consideration of participating in an event hosted by Grace Community, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Grace Community Church, a NYS nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, my actions, physical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and Grace Community, without royalty or other compensation now or in the future, all rights of every kind and character whatsoever, in perpetuity, in and to any and all such recordings, along with any additional recordings I might provide to TTF and Grace Community, and to any benefits incurring to TTF and Grace Community Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Grace Community may, but are not required to, copy or reproduce the recording, edit or modify it, incorporate it into another work, display or broadcast it or any of the foregoing privately or publicly, and use or license it or any of the foregoing for use by others, all for the sole benefit and at the sole discretion of TTF and Grace Community, for the advancement of TTF and Grace Community's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Grace Community Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Grace Community Church, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recordings or use of recordings. This release shall be construed, interpreted and governed in accordance with the laws of the State of Florida, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I am of full age and have the right to contract in my own name*

I understand and agree that my photo, voice, and or activities can be recorded and used in association with the TTF.
Should be Empty:

Guest Information

Transportation and Drop Off

Parent/Caretaker Information

Care Provider Agency Information - Complete all areas if applicable

Night to Shine Parent/Caretaker Media Rights Release