2027 Night to Shine Participant and Caregiver Form

2027 Night to Shine Participant and Caregiver Form

We are so excited to have you be a part of this night!
By filling out this form you CONSENT to have photo / videos taken with you in them.

Photos / videos will be taken by hired photographers / videographers for Ashland Special Needs Ministry and will be posted on our website. Photos / videos may also appear in Ashland Special Needs Ministry's promotional materials.

Ashland Special Needs Minitry is not responsible for where photos / videos end up after being posted on our website.

**If you have any questions please fill out a "Contact Form" at ashlandspecialneeds.com
PLEASE SELECT BELOW
CAREGIVER / PARENT INFORMATION

Information about the caregiver
LAST NAME (Your last name)
FIRST NAME (Your first name)
YOUR EMAIL (This is how we will contact you regarding information for Night to Shine)
example@example.com
YOUR EMAIL (This is how we will contact you regarding information for Night to Shine, confirm your email by entering it again)
example@example.com
YOUR PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
CAREGIVER / PARENT WILL BE:
PARENT RESPITE ROOM NOTES:

THE PARENT RESPITE ROOM HAS IT ALL! FOOD, DRINKS, ENTERTAINMENT, GAMES, GIVE-AWAYS AND MORE! ENJOY THIS RESPITE TIME!

THE PARENT RESPITE ROOM IS LOCATED IN THE SAME BUILDING AS THE DANCE, HOWEVER, PARENTS WILL NOT BE PERMITTED AT THE DANCE WITHOUT PROVIDING A BACKGROUND CHECK TO ASNM PRIOR TO THE EVENT.

IF YOU WOULD LIKE TO BE ABLE TO VISIT YOUR CHILD AT THE DANCE PLEASE EMAIL ASNMTEEVAN@GMAIL.COM AND WE WILL SHARE THE LINK TO COMPLETE A BACKGROUND CHECK.

PLEASE KNOW, ALL VOLUNTEERS ATTENDING THE EVENT ARE BACKGROUND CHECKED TO ENSURE THE SAFETY OF ALL PARTICIPANTS SO THANKS YOU FOR UNDERSTANDING AND HELPING TO KEEP OUR FRIENDS AND FAMILIES SAFE DURING THIS WONDERFUL NIGHT!
NAME OF PARENTS ENJOYING RESPITE ROOM (LIMIT 2)
The parent respite room is for PARENTS ONLY! No children allowed.
PLEASE ADD ANY ALLERGIES THAT MAY AFFECT YOUR ENJOYMENT:
This will help us to serve you better!

PARTICIPANT / GUEST INFORMATION

Information for participant at Night to Shine
LAST NAME (Participant's last name)
FIRST NAME (Participant's first name)
PARTICIPANT'S AGE (must be 14 by 2/5/2027)
PARTICIPANT DATE OF BIRTH (Participant must be 14 by 2/5/2027)

MonthDayYear
PARTICIPANT GENDER:
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMERGENCY CONTACT NAME
EMERGENCY CONTACT PHONE NUMBER

PARTICIPANT MEDICAL / SPECIAL NEEDS INFORMATION

Participant information to help provide the correct support for the evening.
MEDICAL NEEDS NOTE:

NIGHT TO SHINE IS A PROM FOR PEOPLE WITH SPECIAL NEEDS. PLEASE HELP MAKE THIS NIGHT SPECIAL AND LIST THOSE NEEDS BELOW SO THAT WE CAN PROVIDE THE CORRECT BUDDY AND SUPPORT FOR THE EVENING.
MEDICAL NEEDS & DIAGNOSIS:
Example: Autism, Down Syndrome, Cerebral Palsy, etc.
MEDICATION SPECIAL NOTE:

IF MEDICATION ADMINISTRATION IS NECESSARY DURING THE TIME OF THE EVENT, ASHLAND SPECIAL NEEDS MINISTRY WILL NOT BE RESPONSIBLE FOR ADMINISTRATING MEDICATION TO GUESTS AT THE NIGHT TO SHINE EVENT.

IF MEDICATION ADMINISTRATION IS REQUIRED DURING THE EVENT A PARENT OR CARETAKER MUST BE AVAILABLE TO ADMINISTER THE MEDICATION.

(The parent respite room is onsite for parents to relax, eat & enjoy the evening!)
WILL MEDICATION NEED TO BE ADMINISTERED DURING THE EVENT?
ACCESSIBILITY NEEDS:
Example: Ramps, two buddies for assistance, etc.
COMMUNICATION NEEDS:
Example: Non-verbal, ASL, etc.
SENSORY CONCERNS:
Example: No bight lights, no loud music, prefers small crowds, etc.
ALLERGIES:
Example: Please list any and all allergies - including specific food allergies not listed below.
SPECIAL FOOD NEEDS (Choose all the apply):

BUDDIES, STAFF & OTHER INFORMATION

How the participant plans to spend the evening and more about them.
Please tell us some of the participants interests and favorite things:
If participant was to get upset, what might calm them? What are some of their favorite activities?
THE PARTICIPANT IS:
PARTICIPANT WOULD LIKE TO BE PAIRED WITH A ________ VOLUNTEER BUDDY
IF PARTICIPANT WOULD LIKE TO BE PAIRED WITH A SPECIFIC VOLUNTEER, PLEASE TYPE THEIR NAME BELOW:
FIRST NAME & LAST NAME
PARTICIPANT IS BRINGING NURSING OR OTHER STAFF TO ASSIST DURING THE EVENT
Should be Empty:

2027 Night to Shine Participant and Caregiver Form

CAREGIVER / PARENT INFORMATION

PARTICIPANT / GUEST INFORMATION

PARTICIPANT MEDICAL / SPECIAL NEEDS INFORMATION

BUDDIES, STAFF & OTHER INFORMATION