Night to Shine 2019
Guest Registration
Guest Information
First Name *
Your answer
Last Name *
Your answer
Name as you would like to appear on nametag *
Your answer
Age/Date of Birth *
Your answer
Gender *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Fun Fact about You? *
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Emergency Contact during event *
Your answer
Emergency Contact phone number *
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, pollen, etc.)
Your answer
Food needs:
If food needs to be cut up, to what size?
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 medicine.) *
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 to and from event? *
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 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 a part of a group, please include agency or company name)
Your answer
Care Provider Agency Phone:
Your answer
Agency Chaperone: (if applicable) (Note: The chaperone is not required to stay with guest(s) unless required by Care Provider Agency)
Your answer
Additional Notes or Concerns:
Your answer
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