Night to Shine 2018 Guest Registration Form
Night to Shine - February 9, 2018 *** Our capacity for this year is 250 guests. When we reach that limit registration will close.
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:
Your answer
State:
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Zip Code:
Your answer
Email:
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Phone:
Your answer
Fun Fact About You:
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Emergency Contact:
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Emergency Contact Phone:
Your answer
Health Concerns:
Your answer
Wheelchair:
Special Communication Needs:
If yes, please explain:
Your answer
Sensory Issues/Concerns (strobe lights, camera flashes, loud noices, 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
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 part of a group, please include agency or company name)
Your answer
Care Provider Agency Phone:
Your answer
Agency Chaperon (if applicable):
Your answer
Additional Notes or Concerns:
Your answer
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