2019 Rhode Island Night to Shine Guest Registration
Join us on Friday, February 8, 2018 from 6-9pm at the Newport Marriott for a Prom Night you will never forget. Walk the red carpet, enjoy the royal treatment and dance the night away!
Email address *
SEATING IS LIMITED - EVERYONE ATTENDING MUST PRE-REGISTER
First Name: *
Your answer
Last Name: *
Your answer
Name as you would like it to appear on name tag: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Age: *
Your answer
Gender: *
Address (please include city, state and zip code): *
Your answer
Phone Number: *
Your answer
Shirt Size (participant only): *
Fun Fact About You:
Your answer
Favorite Song/Artist
Your answer
Will guest be coming with a special guest/date (other than caretaker)? *
Emergency Contact During Event (Name): *
Your answer
Emergency Contact Phone Number: *
Your answer
Health Concerns: *
Your answer
Wheelchair / Accessibility Device Dependent: *
Special Mobility Needs (cannot use stairs, etc): *
If yes, please explain
Your answer
Special Communications Needs: *
If you need Special Communications, please explain:
Your answer
Sensory Issues / Concerns (strobe lights, camera flashes, loud noises, etc.) Please also tell us about their response/reaction if there were to be an emergency evacuation of any kind so we best know how to help them: *
Your answer
Allergies (list any that apply: foods, animals, latex, makeup, plants or pollen, etc.): *
Your answer
Food Needs (food cut-up or pureed, gluten-free, etc.):
Your answer
Will need medication administered during event? (Please note that OceanPointe Christian 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.): *
How will guest be getting to & from the event? *
Parent / Caretaker Name(s) *
Your answer
Parent / Caretaker Phone Number(s): *
Your answer
Parent / Caretaker will be: *
How many Parent / Caretakers in your group will enjoy the Respite Room? (The Respite Room is a private area where parents/caretakers of guests can spend the evening enjoying food, entertainment and rest while remaining onsite during the event): *
Your answer
Care Provider Agency Name (if attending as a part of a group, please include agency or company name):
Your answer
Care Provider Agency Phone Number:
Your answer
Care Provide Agency Chaperone (if applicable - note, chaperone is not required to start with guest(s) unless required by Care Provider Agency):
Your answer
Additional Notes or Concerns:
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of OceanPointe Christian Church. Report Abuse - Terms of Service