Night to Shine Guest Form
First Ruston will serve as one of more than 450 churches around the world that will host Night to Shine, sponsored by the Tim Tebow Foundation, simultaneously on Friday, February 9, 2018. Night to Shine is an unforgettable prom night experience, centered on God’s love, for people with special needs, ages 14 and older. This worldwide movement is already set to take place next year in all 50 states and 15 countries around the world…and the numbers continue to grow!
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:
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State:
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Zip Code:
Your answer
Email:
Your answer
Phone:
Your answer
Fun Fact About You:
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Emergency Contact During Event:
Your answer
Emergency Contact Phone:
Your answer
Health Concerns:
Your answer
Wheelchair/Accessibility Device Dependent:
Special Communications Needs:
if so explain:
Your answer
Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc:)
Your answer
Allergies:
Your answer
Food Needs: (food cut up or pureed, gluten free, etc.)
If so explain:
Your answer
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 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 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
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