Guest Registration Form
Please return all paperwork by January 25, 2019 as Space is Limited
Guest Information
First Name *
Your answer
Last Name *
Your answer
Name as you would like it to appear on nametag: *
Your answer
Birthday *
MM
/
DD
/
YYYY
Gender *
Street 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 Person 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: foods, animals, latex, makeup, plants or pollen, 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 medications 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
If enjoying Respite Room, how many in group? *
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) *
Your answer
(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)
Additional Notes or Concerns: *
Your answer
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