A Night to Shine - REGISTRATION FORM
GUEST INFORMATION
First Name: *
Your answer
Last Name: *
Your answer
Name as you would like it to appear on nametag: *
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender: *
Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Email:
Your answer
Phone:
Your answer
Fun Fact About You:
Your answer
Emergency Contact (Name): *
Your answer
Emergency Contact Phone: *
Your answer
Health concerns:
Your answer
Wheel Chair: *
Required
Special Communication Needs: *
Required
If yes, please explain communication needs:
Your answer
Sensory Issues / Concerns *
Strobe lights, camera flashes, loud noises, etc.
Required
If yes, please explain sensory issues/concerns:
Your answer
Allergies: *
Food, latex, makeup, plant or pollen allergies, etc.
Required
If yes, please list Allergies:
Your answer
Special Foods Needs: *
Food cut-up or pureed, gluten free, etc.
Required
If yes, list special food Needs:
Your answer
Does this guest plan on having their hair done? *
Required
Does this guest plan on having their makeup touched-up? *
Required
Does this guest plan on having their shoes shined? *
Required
GUEST SPIRITUAL INFORMATION
Guest attends church on a regular basis: *
If yes, what church?
Your answer
Guest is baptized: *
PARENT / CARETAKER INFORMATION
Parent / Caretaker Name(s): *
First and last name(s)
Your answer
Parent / Caretaker Phone: *
Your answer
Parent / Caretaker Phone will be... *
If enjoying the hospitality room, how many?
The Hospitality 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. Radio communication will be available between the hospitality room and the rest of the campus. The dance floor area will also be live-streamed to the hospitality room.
Your answer
CARE PROVIDER AGENCY INFO - 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
LIABILITY FORMS
By checking this box, the registered guest, parents, caretakers, and legally responsible person(s) have read the Media & Liability Rights Release and give consent as listed: tinyurl.com/M-Lrelease *
If you have questions about this, please contact us as soon as possible.
Required
By checking this box, the registered guest, parents, caretakers, and legally responsible person(s) have read the Transportation Liability Release and give consent as listed: tinyurl.com/Transp-release *
If you have questions about this, please contact us as soon as possible.
Required
OTHER
Additional Notes or Concerns:
Your answer
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