Night to Shine Guest and Caretaker Registration Form

Guest and Caretaker Registration

Please be sure the guest and caretaker are both available to fill out the form together. Signatures and information are required for both before submitting. Information on this registration form will be shared with Night to Shine volunteers.

Guest Information

Please fill out this information for the guest who will be joining us for Night to Shine.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Is medication needed during the event? NOTE: Church staff and volunteers are not responsible for medication. The parent/caretaker must stay as the guest's buddy OR stay at the event in the parent room to administer medication when needed.*

YesNo
Is toileting needed during the event? NOTE: Church staff and volunteers are not responsible for toileting. The parent/caretaker must stay as the guest's buddy or stay at the event in the parent room to help with toileting when needed.*

YesNo
Transportation*

Guest Emergency Contact Information

This information will be listed on the guest's nametag at the event.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.

Night to Shine Media Release for Guests
By signing below, and for the good and valuable consideration of participating in an event hosted by Impact Church, 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 Impact Church (“Impact Church”), a South Carolina 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 Impact Church, 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 Impact Church, and to any benefits inuring to TTF and Impact Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Impact Church 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 Impact Church, for the advancement of TTF and Impact Church's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Impact Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Impact 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.
If you agree with the terms of the media release, please select agree. If you do not agree with the terms of the media release, select disagree. Please note that anyone who chooses disagree will have something distinguishing them from other guests so photographers know not to include the guest in any media - photo or video.*

Night to Shine Liability Release for Guests
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES
associated with the “NIGHT TO SHINE” EVENT hosted by Impact Community Church of York County on February 7, 2025, at Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County and ACL Headquarters of York County, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible
liability without fault. I acknowledge that this Accident Waiver and Release of Liability will be used by the event holders, sponsors, and organizers of the activity in which I may participate and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs,
next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not
limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: The Tim Tebow Foundation and/or their directors, officers, employees, volunteers, representatives, and agents, and Impact Community Church of York County, Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County, ACL Headquarters of York County, the activity holders, sponsors, and volunteers;

(B) INDEMNIFY, HOLD HARMLESS AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that Impact Community Church of York County, Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County, ACL Headquarters of York County, and the Tim Tebow Foundation and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS
CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A
CONTRACT, AND I AGREE TO IT OF MY OWN FREE WILL.
Once you have read the liability release, please check the box below.*

Yes, I have read the liability release and accept the terms.

Thank you for completing the guest portion of the registration! Please sign your name, type your name, and enter the date as confirmation that you have filled out the form to the best of your ability, understand the expectations for the event, and have read and understand both the media and liability releases.
Guest Signature (or signature of person legally responsible for guest)*

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Guest Name (or name of person legally responsible for guest)*

First NameLast Name
Date*

MonthDayYear
Date

Caretaker Information

Please note: Guests are allowed only ONE caretaker at the event. The caretaker can be the guest's buddy throughout the night as part of the event (background check required), spend the event time in the respite room, OR simply drop-off and pick-up the guest. You will indicate your choice below. If you choose to be the guest's buddy, you will get an email to complete a background check and information about a required training in January. If you do not do the background check and training, you WILL NOT be allowed to attend the event. For the safety of our guests, no exceptions will be made. If you choose to not be a buddy, a volunteer buddy will be assigned to the guest.
Name*

First NameLast Name
The caretaker will..*

Drop-off and pick-up the guest for the event (will not stay on site)Stay to enjoy food and entertainment in the respite room during the eventBe the guest's buddy for the event (stay on site with guest and participate with guest entire night for seated dinner and dancing) *background check and training required for entry
What is the caretaker's relationship to the guest?*
Caretaker Phone Number*
Please enter a valid phone number.
Caretaker Email
This email will be used to send the required background check information if you are a buddy.
If you will NOT be the guest's buddy during the event, is there anything you want to share with the volunteer buddy about the guest that will help them make this an enjoyable and memorable experience? Please also use this space if you would like to request a specific buddy (put the buddy name in the box). If not applicable, put n/a. *

Night to Shine Media Release for Caretakers
By signing below, and for the good and valuable consideration of participating in an event hosted by Impact Church, 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 Impact Church (“Impact Church”), a South Carolina 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 Impact Church, 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 Impact Church, and to any benefits inuring to TTF and Impact Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Impact Church 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 Impact Church, for the advancement of TTF and Impact Church's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Impact Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Impact 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.
If you agree with the terms of the media release, please select agree. If you do not agree with the terms of the media release, select disagree. Please note that any caretaker volunteering as a buddy who chooses disagree will have something distinguishing them from other buddies so photographers know not to include the guest in any media - photo or video.*

Night to Shine Liability Release for Caretakers
I HEREBY ASSUME ALL OF THE RISKS OF PARTICIPATING IN ANY/ALL ACTIVITIES
associated with the “NIGHT TO SHINE” EVENT hosted by Impact Community Church of York County on February 7, 2025, at Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County and ACL Headquarters of York County, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible
liability without fault. I acknowledge that this Accident Waiver and Release of Liability will be used by the event holders, sponsors, and organizers of the activity in which I may participate and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs,
next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not
limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: The Tim Tebow Foundation and/or their directors, officers, employees, volunteers, representatives, and agents, and Impact Community Church of York County, Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County, ACL Headquarters of York County, the activity holders, sponsors, and volunteers;

(B) INDEMNIFY, HOLD HARMLESS AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise. I acknowledge that Impact Community Church of York County, Rock Hill Sports and Event Center of York County, Knowledge Perk LLC and Knowledge Perk Holdings, LLC of York County, ACL Headquarters of York County, and the Tim Tebow Foundation and their directors, officers, volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity. The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.

I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS
CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A
CONTRACT, AND I AGREE TO IT OF MY OWN FREE WILL.
Once you have read the liability release, please check the box below.*

Yes, I have read the liability release and accept the terms.N/A - select ONLY if you are a caretaker who is not planning to stay for the event. Do not pick this if you are staying as a caretaker or in the respite room.

Thank you for completing the caretaker portion of registration! Please sign your name, type your name, and enter the date as confirmation that you have filled out the form to the best of your ability, understand the expectations for the event, and have read and understand both the media and liability releases.
Caretaker Signature*

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Caretaker Name*

First NameLast Name
Date*

MonthDayYear
Date

Care Provider Agency Information

If applicable, please fill out the information below.
Agency Name
Agency Phone Number
Please enter a valid phone number.

When you have finished all of the required information for both the guest and caretaker, please hit submit! Someone will be in contact with you soon with more information. We look forward to having you at our event!
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Guest and Caretaker Registration

Guest Information

Guest Emergency Contact Information

Guest Health Needs

Night to Shine Media Release for Guests

Night to Shine Liability Release for Guests

Caretaker Information

Night to Shine Media Release for Caretakers

Night to Shine Liability Release for Caretakers

Care Provider Agency Information