Night to Shine Guest Registration

Night to Shine Registration

February7, 2025 Hosted by Calvary Chapel & Gateway Church
SPONSORED BY THE TIM TEBOW FOUNDATION
Guest Information
Name

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

MaleFemale
DOB
Address
City
Zip Code
Email
example@example.com
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?

YesNo
* 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?

YesNo
We would love to make your Night to Shine experience the best it can possibly be. If you are comfortable sharing, please answer any of the following optional items that apply in order to help us offer the best support we can.
Health Concerns
Will be attending prom in a wheelchair?

Yes, in a standard/regular wheelchairYes, in a fully reclined wheelchairNo
Will guardian/parent/aide be attending the prom with guest?

YesNo
Any other 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

* If you are part of a Group Home/Aide/ Care provider Agency, please skip and fill out your portion below*
Caretaker Name(s)
Caretaker Phone
Caretaker relationship to guest
Caretaker will be...

Attending Prom with guestEnjoying Respite Room*Only Dropping Guest Off
If enjoying Respite Room*, please list Caretakers.
Name 1
Name 2
* 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

Group Home please fill out
Care Provider Agency (If attending as a part of a group, please include agency or company name)
Care Provider Agency Phone
Name of Agency/Group Aide that will attend the prom with guest(s):
Agency/Group Aide Cell Phone:
Note: Chaperone is not required to stay with guests unless required by Care Provider Agency. If Chaperone remains with guest, a current Background Check will be required
Please provide contact number if we have any questions about this reservation (main Caretaker and Agency provided above)
Additional Notes or Concerns
Media Release
If you haven't already done so, please complete the Media Release Form by clicking here. This form is required to complete registration. Once you're done return to this page to finish submitting your registration!
Have you submitted your Media Release Form?*

Yes
Calvary Chapel Staten Island

30 Maple Parkway

Staten Island, NY 10303

www.calvarychapelsi.org

EMAIL: Nighttoshine2024ccsi@gmail.com
Should be Empty:

Night to Shine Registration

Guest Information

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

Caretaker Information

Care Provider Agency Information - If Applicable

Media Release