Night to Shine 2018
Registration Form
Email address *
Guest Information
First *
Your answer
Last *
Your answer
Name as you would like it to appear on name tag: *
Your answer
Date of Birth *
Your answer
Gender: *
Required
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Phone:
Your answer
Fun Fact about you:
Your answer
Emergency Contact during event:
Your answer
Emergency Contact Phone:
Your answer
Health 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: food, latex, makeup, plant or pollen allergies, etc.)
Your answer
Food Needs (food cut-up or pureed, gluten free, etc.): *
If yes, please 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? *
If yes, please indicate name of group and contact number:
Your answer
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