Night to Shine Guest Information

Please fill out this form and click submit.

Participant's Full Name

Name as you would like it to appear on name tag

Date of Birth

Gender

Please select all that apply.

Male Female

Address

Phone

Participant's Email

This address will receive a confirmation email

Fun fact about you

Emergency contact name and number (will be included on name tag)

Guest will need medication administered during event (please note that the church, their staff, or 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)

Please select all that apply.

Yes No

Will guest be dropped off and picked up by parent/caretaker?

Please select all that apply.

Yes No

Will guest be taking public transportation to and from event?

Please select all that apply.

Yes No

Will guest be attending as a part of a group that will provide transportation?

Please select all that apply.

Yes No

Group name

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.

Any health concerns, mobility needs, communication needs, sensory issues/concerns (strobe lights, camera flashes, loud noises, etc.), or food needs (dairy/gluten/nut free, pureed or cut up, etc.)?

Any additional notes or concerns we should be aware of that will help us to make this event wonderful for this guest?

Caregiver Information

Caregiver's Name

Caregiver's Phone

A respite room is a space specifically designed to care for caregivers! In a space all your own, we will provide food and entertainment. Knowing this, caregiver will be...

Please select all that apply.

Dropping off Staying respite room

If enjoying the respite room, please list up to two caregivers for your guest

Caregiver relationship to guest

Care Providers 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)

Agency chaperone cell phone

By clicking this, I accept this as my signature

Please select all that apply.

Yes

Description

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Night to Shine Guest Information

Description

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