Guest Registration Night to Shine
Email address *
Guest Information
First Name *
Your answer
Last Name *
Your answer
Name as you would like it to appear on name tag if different
Your answer
Age of Guest *
Your answer
Date of Birth *
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Gender *
Guest Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email *
Your answer
Phone Number *
Your answer
List Guest Health Concerns (i.e., diagnosis, diabetes, seizures etc. Be specific) *
Your answer
Date of Last Seizure *
Your answer
List Allergies (i.e., foods, latex, make up, plant/flowers etc.): *
Your answer
Do you have Special Food Needs (i.e., food cut up, pureed, gluten free, etc. ) *
Your answer
Will you be arriving in a wheelchair? *
Are you able to transfer into a van/limo with steps? *
Other mobility concerns/needs *
Your answer
Is the participant verbal or non-verbal? *
If non-verbal what communication device is used? (i.e., sign language, requires extra time, uses an iPad, picture board, etc.) *
Your answer
List of Sensory or Behavior Issues/Concerns (i.e., strobe lights, camera flashes, loud noises, etc.) *
Your answer
List strategies to assist for calming or redirection *
Your answer
Provide Fun Facts About you (i.e., hobby/interests, favorite music, singer, sports team, etc.) *
Your answer
Additional Activities Available
Please indicate if you would like one or more of the following
Hair *
Make Up *
Shoe Shine *
*Please note a designated time for your arrival will be provided to you on your confirmation within a week of the event*
Guardian/Parent/Caretaker Information
Guardian/Parent/Caretaker Name *
Your answer
Guardian/Parent/Caretaker Phone *
Your answer
Guardian/Parent/Caretaker who will be dropping guest off/picking up *
Your answer
Emergency Contact for the Night to Shine event (if different than name listed above) *
Your answer
Emergency Contact Phone for the Night to Shine event (if different than number listed above) *
Your answer
Do you plan to remain with Guest for night as their escort/buddy? *
If yes, please provide the name of person staying with the Guest *
Your answer
Do you want a Night to Shine assigned buddy in addition to the family escort? *
A respite room is provided on site to serve as a private area where guardians/parents or caretakers of guests can spend the evening in a separate area enjoying food, entertainment and rest while remaining onsite during the event
Do you plan to stay and enjoy the Respite Room activities? *
If enjoying Respite Room, how many people? *
Your answer
Please note due to space limitations for our guests and buddies, guardians/parents/caretakers are welcome to take pictures upon arrival or throughout event but we highly encourage utilization of the respite room
Provider Agency Information- if applicable
Provider Agency *
Your answer
Provider Agency Contact Name *
Your answer
Provider Agency Phone *
Your answer
Name of Agency Chaperone for event night (if applicable) (Note: Chaperone is not required to stay with guests unless required by care provider agency) *
Your answer
Does your resident require 1:1 assistance? *
If yes, please provide name of chaperone from your agency providing 1:1 escort at all times *
Your answer
Do you want a Night to Shine Buddy in addition to your provided chaperone?
Additional Notes or Concerns that will assist in providing a great experience *
Your answer
Night to Shine Participant Media & Liability Rights Release
By signing below, and for the good and valuable consideration of participating in an event hosted by Florence United Methodist Church, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Florence United Methodist Church, a Kentucky nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, the actions, physical likeness, biographical information, and/or voice of me and/or any person of whom I am the parent or legal guardian, including minor children (collectively referred to as the “Participants”). Additionally, I hereby grant to TTF and Florence United Methodist Church, without royalty or other compensation now or in the future, all rights of every kind and character whatsoever, in perpetuity, in and to any and all such recordings, along with any additional recordings I might provide to TTF and Florence United Methodist Church, and to any benefits inuring to TTF and Florence United Methodist Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Florence United Methodist Church may, but are not required to, copy or reproduce the recording, edit or modify it, incorporate it into another work, display or broadcast it or any of the foregoing privately or publicly, and use or license it or any of the foregoing for use by others, all for the sole benefit and at the sole discretion of TTF and Florence United Methodist Church, for the advancement of TTF and Florence United Methodist Church’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Florence United Methodist Church and bind the Participants and their heirs, successors, and assigns. I, on behalf of all Participants, hereby release and discharge and agree to hold harmless TTF and Florence United Methodist Church, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recording or use of the recordings. This release shall be construed, interpreted and governed in accordance with the laws of the State of Florida, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I am of full age and have the right to contract in my own name and for each Participant.AGREED TO AND ACCEPTED:Name of Participant: *
Your answer
Date *
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Signature of Participant (if over age 18) *
Your answer
Signature of Parent/Caretaker (if participant is under age 18) *
Your answer
Address *
Your answer
Telephone *
Your answer
City/State/Zip *
Your answer
Email *
Your answer
Communications
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: *
Required
Signature of Parent/Caretaker *
Your answer
Date *
MM
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Please complete the part below if the guest is under 18 and parent/caretaker plans on staying at the event. Night to Shine Parent/Caretaker Media & Liability Rights Release:
By signing below, and for the good and valuable consideration of participating in an event hosted by Florence United Methodist Church, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Florence United Methodist Church, a Kentucky nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, my actions, physical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and Florence United Methodist Church, without royalty or other compensation now or in the future, all rights of every kind and character whatsoever, in perpetuity, in and to any and all such recordings, along with any additional recordings I might provide to TTF and Florence United Methodist Church, and to any benefits inuring to TTF and Florence United Methodist Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Florence United Methodist Church may, but are not required to, copy or reproduce the recording, edit or modify it, incorporate it into another work, display or broadcast it or any of the foregoing privately or publicly, and use or license it or any of the foregoing for use by others, all for the sole benefit and at the sole discretion of TTF and Florence United Methodist Church, for the advancement of TTF and Florence United Methodist Church’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Florence United Methodist Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Florence United Methodist Church, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recording or use of the recordings. This release shall be construed, interpreted and governed in accordance with the laws of the State of Florida, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I am of full age and have the right to contract in my own name.AGREED TO AND ACCEPTED: Name of Parent/Caretaker:
Your answer
Date
MM
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Signature of Parent/Caretaker
Your answer
Address
Your answer
Telephone
Your answer
City/State/Zip
Your answer
Email
Your answer
Participant Name
Your answer
Florence United Methodist Church
8585 Old Toll Road, Florence, KY 41042
Contact Name: Doris Daugherty
Email: doris@florenceumc.com
Fax: 859-371-5608
Office: 859-371-7961
A copy of your responses will be emailed to the address you provided.
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