Night to Shine 2018 Registration
Night to Shine, sponsored by The Tim Tebow Foundation, is designed for anyone ages 14 and older with developmental and/or physical impairments. Each participant will be paired with a Night to Shine "Buddy" volunteer. If a participant has specific medical and/or behavioral issues, they are required to attend with their own chaperone.
GUEST INFORMATION
First Name: *
Your answer
Last Name: *
Your answer
Name as you would like it to appear on nametag: *
Your answer
Age/DOB: *
Your answer
Gender: *
Address: *
Your answer
City/State/Zip Code *
Your answer
Email Address (Guest's or Caretaker's): *
Your answer
Phone Number: *
Your answer
Fun Fact About You:
Your answer
Emergency Contact During the Event: *
Your answer
Emergency Contact Phone: *
Your answer
Health Concerns: *
Your answer
Wheelchair/Accessibility Device Dependant? *
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: food, animals, latex, makeup, plant or pollen, etc.)
Your answer
Food Needs: *
(food cut-up or pureed, gluten free, etc.)
If yes, please explain:
Your answer
Need Medication Administered During Event? *
Please note that Compass 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.
PARENT/CARETAKER INFORMATION
Parent/Caretaker Name(s):
Your answer
Parent/Caretaker Phone:
Your answer
Parent/Caretaker will be::
If enjoying respite room, how many?
*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 INFORMATION - IF APPLICABLE
Care Provider Agency:
(If attending as a part of a group, please include agency or company name)
Your answer
Care Provider Agency Phone:
Your answer
Agency Chaperone (if applicable):
(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)
Your answer
Additional Notes or Concerns:
Your answer
COMMUNICATION RELEASE
Communication Release *
I acknowledge TTF staff members and/or volunteers may contact the Participant to discuss their experience at the event, encourage, pray for, or receive general updates. I hereby give my full consent to TTF to contact the Participant after the event directly through the following means:
Communication Release Signature *
Please enter your signed release by typing your name
Your answer
Communication Release is Signed By: *
MEDIA & LIABILITY RELEASES
Please complete both liability releases before submitting form.
Parent/Caretaker Media & Liability Rights Release - if applicable - (must be read and agreed to in order to attend)
(Please click link to read release form) https://drive.google.com/file/d/0BwKEz8iTHAlqR1hYQlhHeVVnLTA/view (to sign release, please type your name and date below)
Your answer
Participant Media & Liability Rights Release - (must be read and agreed to in order to attend) *
(Please click link to read release form)https://drive.google.com/file/d/0BwKEz8iTHAlqc0RrX1k4dWNCZEE/view (to sign release, please type your name & date below)
Your answer
Participant Media & Liability Rights Release was signed by: *
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