Night to Shine Guest Registration
Will will follow up with more information about the event as we get closer to the date. Thank you for registering for what we know is going to be a great night. We look forward seeing you!
First Name *
Your answer
Last Name *
Your answer
How did you hear about our event?
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Fun fact about you. What are passionate about? What do you love to do? *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Heath Concerns *
Your answer
Wheelchair / Accessibility Device Dependent *
Special Communication Needs *
If yes, please explain
Your answer
Sensory Issues / Concerns (strobe lights, camera flashes, loud noises, etc.)
Your answer
Allergies (Please 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: The Church staff or volunteers are not responsible for administering medications to guests at 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 the event? *
Will guest be attending as a part of a group that will provide transport? *
Parent Caretaker Names and phone numbers *
Your answer
Parent / Caretaker will be... *
If staying, how many will be joining us in the respite room? *
Your answer
Care Provider Agency *
Your answer
Care Provider Agency Phone *
Your answer
Agency Chaperone (if applicable) *
Your answer
Additional Notes and Concerns
Your answer
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