Night to Shine Participant and Caregiver Form

1

Please type your email here:ex: joe@gmail.com

example@example.com

2

Please check you have typed the correct email above. This is to ensure you receive all communication about this special night via this email* This field is required.Please take a second look.

Yes, this is the correct email.

3

First Name* This field is required.Participant's first name

4

Last Name* This field is required.Participant's last name

5

Date of Birth- please note the participant must be 14 by 2/7/2026* This field is required.Participant's date of birth

Date

6

Gender* This field is required.Please choose one of the following:

Male

Female

7

Address* This field is required.Residence

8

Phone Number* This field is required.Cell or home

9

Emergency Contact Name* This field is required.Who may we contact in an emergency?

10

Emergency Contact Phone Number* This field is required.Phone number for emergency contact

11

Medical Needs and Diagnosis*Please note: this is a prom for people with special needs. Please list those needs here so that we can provide the correct buddy and support for the evening. Thank you!* This field is required.Example: Autism/Down Syndrome/Etc.

12

Please Note that if medication administration is necessary during the time of the event, Ashland Special Needs Ministry will not be responsible for administrating medication to guests during the Night to Shine event. If medication administration is required during the event, a parent or caretaker MUST be available to administer the medication. (Parent Respite Room is on site for parents to relax, eat, and enjoy the evening.)Please note if you will need to administer meds during the event.

Please make sure all arrangements are made for medications for your loved ones and those in your care.

13

Accessibility Needs* This field is required.Example: Ramps, two buddy for assisting with getting out of chair, etc.

14

Communication Needs* This field is required.Non-verbal, ASL, etc.

15

Sensory Concerns* This field is required.No bright lights, no loud music, prefers smaller crowds, etc.

16

Allergies* This field is required.Please include any and all allergies.

17

Food Needs* This field is required.Please mark all that apply.

No assistance necessary

Needs assistance eating

Gluten Free

Dairy Free

Food needs to be pureed

Liquid Diet

18

If nursing staff is necessary, please make note of that in the 'Additional Notes' sectionNote: if the participant is bringing staff to assist them throughout the night, the staff needs to register as a volunteer.

Staff will need to return to website and register as volunteer.

19

Interests and Favorite things* This field is required.If participant were to get upset, what might calm them?

20

Participant is* This field is required.

Part of a group home and will be coming with staff member who will stay with this individual (staff member must register as volunteer).

Part of a group home and will NOT be coming with staff member (would like a volunteer buddy for the evening).

Coming with parent and would like a buddy.

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Note: if the participant is bringing staff to assist them throughout the evening, each staff member needs to register as a volunteer.Please visit ashlandspecialneeds.com

22

Guest would like to be paired with a _____ volunteer* This field is required.Please choose one.

Male

Female

does not matter

**is coming with group home staff as stated before**

23

If the participant is requesting to be paired with a volunteer who is coming please type their name below to ensure they are paired with the correct volunteer request. Leave blank if Not Applicable.Please give first and last name.

24

Additional Notes/Anything that will help us serve this individual better* This field is required.Thank you for anything you can provide!

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*We have rented limousines and accessible transportation for rides through downtown Ashland during the evening. All participants will register at the main entrance before entering the event. (Please see email that will come closer to the event with all the details including parking information).Drop off directions will be emailed prior to the event

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By filling out this form, you CONSENT to have photo/videos taken with you in them. Photos/videos will be taken by hired photographers/videographer for Ashland Special Needs Ministry, and will be posted on our website. Photos/videos may appear in Ashland Special Needs Ministry's promotional material. Ashland Special Needs Ministry is not responsible for where photos end up after being posted to our website. **If you have questions, please fill out a 'Contact' form at ashlandspecialneeds.comPlease select one

I give consent

I do not give consent

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First and Last Name* This field is required.Please type name

28

Phone Number* This field is required.Please type number

29

Caregiver will be * This field is required.Please choose one

dropping guest off and leaving

staying to enjoy the provided Respite Room on campus

Is a provider from a group home and will be enjoying the Provider Room on campus

30

*Please note: Parent respite room will be in the same building as the dance; however, parents will not be permitted in the dance without providing a background check to ASNM prior to event. Our volunteers will be background checked to ensure safety of all participants! Thank you for understanding and helping to keep our friends and family safe during this wonderful night! * If you would like to be able to visit your child in the dance, please send an email to asnmteevan@gmail.com and we will send you the background check link.If you wish to be 'at' the dance, you will need to register as a volunteer and complete a background check. We truly hope you will take advantage of the Parent Respite Room.

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Name of Parents enjoying Respite Room (Limit Two, Parent Respite Room is for parents only. Please respect this space and this time of respite for the parents attending. No children, thank you.)Food, beverage, entertainment, games, and give-aways!

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Parent: Please add any allergies here that may affect your enjoyment of this evening:This will help us better serve you