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Night to Shine 2019
Registration Form
Email address *
GUEST INFORMATION
First *
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Last *
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Name as you would like it to appear on name tag: *
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Date of Birth *
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Gender: *
Required
Address: *
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City: *
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State: *
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Zip Code *
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Phone: *
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Email Address of Parent/Caretaker (we will be sending important information by email) *
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Fun Fact about you:
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Please share with us 2-3 things that would help ensure you enjoy the night.
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Emergency Contact During Event: *
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Emergency Contact Phone: *
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I am an individual who: (please check all that apply)
Health Concerns:
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Wheelchair/Accessibility Device Dependent: *
Special Communication Needs: *
If yes, please explain:
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Sensory Issues/Concerns (strobe light, camera flashed, loud noises, etc.):
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Allergies: (Please list any that apply: food, latex, makeup, plant or pollen allergies, etc.)
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Food Needs (food cut-up or purees, gluten free, etc.):
If yes, please explain:
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Will need medication 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 a parent/caretaker? *
Will quest be taking public transportation to and from event? *
Will guest be attending as a part of a group that will provide transportation? *
If yes, please indicate name of group and contact number:
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