Guest Registration Form

* = required field

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: