First name:
Last name:
Name as you would like it to appear on name tag:
Birthday:
Month
Day
Year
Gender:
Male
Female
Multi-line address
Country/Region
Address
City
Zip / Postal code
Email
Phone
Fun Fact About You:
Emergency Contact name/number during event (will be listed on guest’s name tag):
Will Need Medication Administered During Event:
Yes
No
* 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 me
Will guest be dropped off and picked up by parent/caretaker?
Yes
No
Will guest be taking public transportation to and from event?
Yes
No
We would love to make your Night to Shine experience the best it can possibly be. If you are comfortable sharing, please answer any of the following optional items that apply in order to help us offer the best support we can.
Health Concerns:
Mobility Needs:
Communication Needs:
Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.):
Allergies: (Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.)
Food Needs
Cut-up
Pureed
Gluten free
Dairy free,
Nut free,
None
Additional Notes/Concerns You Would Like Us to Be Aware Of
Caretaker Name(s):
Caretaker Phone:
Caretaker will be
Dropping Guest Off:
Enjoying Respite Room:
If enjoying Respite Room*, please list up to two guest:
Additional Notes or Concerns:
Submit
Guest Registration