Night to Shine - GUEST Registration From

Please complete this GUEST registration form for Night to Shine.

Your name *

Email address *

Birthdate

Phone number

Address

Gender

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): *

Check If Medication Will Need to be Administered During Event:

* 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? *

Yes

Will guest be taking public transportation to and from event? *

Yes

Will guest be attending as a part of a group that will provide transportation?

Yes

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:

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

Caretaker Name(s):

Caretaker Phone:

Caretaker will be… *

Dropping Guest Off

Enjoying Respite Room

Caretaker relationship to guest

If enjoying Respite Room* , please list Caretakers:

* 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

Care Provider Agency:

(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 guest(s) unless required by Care Provider Agency . If

Chaperone remains with guest, a current Background Check will be required.)

Additional Notes or Concerns:

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