2024 WAITLIST Night to Shine Guest Registration

Friday, February 7, 2025
6-9P
First Christian Church
3601 S Staley Rd
Champaign, IL 61822

Non-transferrable. For people with special needs 14+.

Guest Name*

First NameLast Name

Guest Name Tag*

Name to be displayed on event name tag

Guest Date of Birth*

MM/DD/YYYY

Guest Gender*

MaleFemale

Best contact email *

example@example.com

Best contact phone number*

Area CodePhone Number

Preferred Buddy Request (We will try to accommodate all special buddy requests but cannot guarantee special placements. A buddy is a volunteer that spends the evening with each guest; this is NOT a date but someone who is volunteering for the evening.)

First NameLast Name

ATTENTION

Please fill in as many of the following details so we can be prepared to serve our guests well.

Health Concerns

Wheelchair?

YesNo

Special Communication Needs

Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.)

Allergies (makeup, latex, plants, pollen, foods, etc.)

Fun fact about the guest

Bathroom Needs

Self careNeeds assistance

Sensory Room

We will be providing a special room where guests who are sensitive to loud noises, bright lights, large crowds, etc. can enjoy sensory friendly activities, such as singing lightly, crafts, etc.

Will the guest be taking advantage of the Sensory Room?

YesNo

The food menu is as follows:

Chicken Nuggets
Tater tots/chips
Fruit
Cupcakes/Cookies

*Special menus will not be offered. Feel free to bring a meal if you cannot have the specified meal.

Parent/Caretaker Name*

First NameLast Name

Parent/Caretaker Name (2)

First NameLast Name

Parent/Caretaker Phone Number*

Area CodePhone Number

Parent/Caretaker Email*

example@example.com

Respite Room

We have a special place set up for parents and caretakers. There will be food and entertainment, as well as conversation, prayer, and encouragement. Enjoy your evening only steps away from the event. We will call you in the case of any emergency.

Parent/Caretaker will be:*

Dropping guest offStaying to enjoy respite room

How many parent/caretakers will be enjoying the Respite Room?

12

Night to Shine Parent/Caretaker Media Rights Release

By signing below, and for the good and valuable consideration of participating in an event hosted by First Christian 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 First Christian Church, a Illinois 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 First Christian 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 First Christian Church, and to any benefits inuring to TTF and First Christian Church as a result of its use of any of the foregoing recordings. Among other things, TTF and First Christian 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
First Christian Church, for the advancement of TTF and First Christian Church's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and First Christian Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold
harmless TTF and First Christian 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.

AGREED TO AND ACCEPTED:

Name of Parent/Caretaker (1) enjoying to Respite Room

First NameLast Name

Date

Signature of Parent/Caretaker (1)*

Name of Parent/Caretaker (2) enjoying Respite Room

First NameLast Name

Date

Signature of Parent/Caretaker (2)*

Additional Emergency Contact Name*

First NameLast Name

Additional Emergency Contact Phone Number*

Area CodePhone Number

Care Provider Agency Information - If Applicable

Care Provider Agency Name

Care Provider Agency Phone Number

Area CodePhone Number

Agency Chaperone

First NameLast Name

Night to Shine Participant Media & Liability Rights Release

By signing below, and for the good and valuable consideration of participating in an event hosted by First Christian 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 First Christian Church (“CHURCH”), an Illinois nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, the actions, physical likeness, biographical information, and/or voice of me and/or any person of whom I am the parent or legal guardian, including minor children (collectively referred to as the “Participants”). Additionally, I hereby grant to TTF and 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 CHURCH, and to any benefits inuring to TTF and CHURCH as a result of its use of any of the foregoing recordings. Among other things, TTF and 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 CHURCH, for the advancement of TTF and CHURCH’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and CHURCH and bind the Participants and their heirs, successors, and assigns. I, on behalf of all Participants, hereby release and discharge and agree to hold harmless TTF and 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 recording or use of the 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 and for each Participant.

AGREED TO AND ACCEPTED:

Name of Participant*

First NameLast Name

Date*

Date

Signature of Participant (if over age 18)

Registration is null without Participant or Parent/Caretaker Signature

Signature of Parent/Caretaker (if participant is under age 18)

Registration is null without Participant or Parent/Caretaker Signature

Address of Participant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Communication Release

I acknowledge TTF staff members and/or volunteers may contact the participant to discuss their experience at the event, encourage, pray for, or receive general updates. I hereby give my full consent to TTF to contact the participant after the event directly by the following means:

(choose any that apply)*

Signature*

Click and drag mouse to sign. Registration is null without Signature

Date*

Date

2025 Night to Shine WAITLIST Guest Registration