Night to Shine Registration

Name

First NameLast Name

Name as you would like it to appear on nametag

DOB

Address

City

State

Zip Code

Email

example@example.com

Phone

Fun Fact About You

Emergency Contact during event will be listed on guests nametag

Emergency Contact Phone will be listed on guests 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 and picked up by parent/caretaker?

YesNo

Will guest be taking public transportation to and from event?

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 thatapply in order to help us offer the best support we can.

Health Concerns

Mobility Needs

Communication Needs

Sensory IssuesConcerns strobe lights camera flashes loud noises etc

Allergies: (Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc

Food Needs food cutup or pureed gluten free dairy free nut free etc

Additional NotesConcerns You Would Like Us to Be Aware Of

Caretaker Names

Caretaker Phone

Caretaker will be Dropping Guest Off:

Caretaker will be:

Dropping Guest offEnjoying Respite Room

Caretaker relationship to guest

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

(If attending as a 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 guests unless required by Care Provider Agency. If Chaperone remains with guest, a current Background Check will be required

Additional Notes or Concerns

Guest Information