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Night to Shine Registration

First Name
Last Name
Name as you want it to appear on name tag
Age/DOB
Gender	Male Female
Address
City
State/Region
Zip/Postal Code
Email
Phone
Fun Fact About You
Emergency Contact During Event (will be listed on name tag)
Emergency Contact Phone (will be listed on name tag)
Health Concerns
Wheelchair/Accessibility Device Dependent	Yes No
Special Communication Needs	Yes No
If Yes, Please Explain:
Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.)
Food Needs food cut-up or pureed, gluten free, dairy free, etc.)	Yes No
If Yes, Please Explain
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 medication.
Will guest be dropped off and picked up by a paren	Yes No
Will guest be taking public transportation to and	Yes No
Will guest be attending as a part of a group that	Yes No
Additional Notes/Concerns You Would Like Us to Be
Parent/Caretaker Information
Parent/Caretaker Name
Parent/Caretaker Phone
Parent Caretaker will be	Dropping off Enjoying Respite Room
If 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.
Care Provider Agency Information (if applicable)
Care Provider Agency Information (if applicable)
Care Provider Agency Phone
Agency Chaperone (if applicable)
(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)
Additional Notes or Concerns

* required field

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