Shine Prom Guest Registration
Email address *
FIRST name of guest *
Your answer
LAST name of guest *
Your answer
Guest birth date *
MM
/
DD
/
YYYY
Guest's numerical age *
*must be 13 years old by 10/19/2019
Your answer
Gender *
Preferred guest name for name tag *
Your answer
PRIMARY Parent/Caregiver name *
Your answer
PRIMARY Parent/Caregiver relationship to guest *
Your answer
Primary Parent/Caregiver Cell *
000-000-0000
Your answer
Primary Parent / Caregiver Email Address *
Your answer
Additional Parent / Caregiver Email Address *
Your answer
Emergency Contact Name and Relationship *
Your answer
Emergency Contact Cell Phone *
000-000-0000
Your answer
At least one parent/caregiver must remain INSIDE the SportsPlex for the entire event (no more than 2 parents or caregivers please.) Respite room is available and prom can be viewed from the track above the gymnasium. Parent (s)/ caregiver (s) will be: *
Does guest live in a group home or other similar facility? *
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