Guest Registration Form

* = required field

Thank you for your interest in the 2018 Tim Tebow Night to Shine Prom hosted at Longview Point Baptist Church! With such an overwhelming response to the event, we have now met our capacity limit. We do have a waitlist for this event, so please fill free to register below to be put on our waitlist. Thanks and have a blessed day.

Guest Information

 
* First Name:
* Last Name:
* Name as you would like it to appear on nametag:
* Date of Birth:    
Gender:
Address Line 1:
Address Line 2:
Address Line 3:
City:
State:
Zip:
Phone:
* Email:
Fun Fact About You
* Emergency Contact Name:
* Emergency Contact Phone:
Health Concerns:
Wheelchair/Accessibility Device Dependent:
Special Communication Needs:
If yes, please explain:
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
(food cut-up or pureed, gluten free, etc.):
If yes, please explain:

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 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):
Parent/Caretaker Phone:
Parent/Caretaker will be…
If enjoying 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:
(If attending as a part of a group, please include agency or company name)
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: