Night to Shine 2020 Registration
Friday, February 7, 2020, 6:00 pm to 9:00 pm
Beechland Baptist Church, 4613 Greenwood Road, Louisville, KY 40258
directions: https://goo.gl/tUHpQF
Email address *
Guest information:
First Name *
Your answer
Last Name *
Your answer
Name as you would like it to appear on nametag *
Your answer
Age/DOB *
MM
/
DD
/
YYYY
Gender *
Address *
Your answer
City: *
Your answer
State *
Your answer
Zip Code *
Your answer
Fun Fact About You
Your answer
Emergency Contact Phone *
Your answer
List any Health Concerns
Your answer
Wheelchair/Accessibility Device Dependent *
List any Special Communication Needs
Your answer
List any Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.)
Your answer
List any Allergies (Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.)
Your answer
List any Food Needs (food cut-up or pureed, gluten free, etc.)
Your answer
Will guest 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 guest be taking public transportation to and from event? *
Will guest be attending as a part of a group that will provide transportation? *
Parent/Caretaker Information:
Parent/Caretaker Name(s) *
Your answer
Parent/Caretaker Phone *
Your answer
Parent/Caretaker will be… *
If Enjoying Respite Room, how many?
Your answer
* 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.
Care Provider Agency Information – If Applicable:
Care Provider Agency – If Applicable
Your answer
Care Provider Agency Phone – If Applicable
Your answer
Agency Chaperone – If Applicable
Your answer
(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider
Agency)
Additional Notes or Concerns:
Your answer
A copy of your responses will be emailed to the address you provided.
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