Name as you would like it to appear on nametag:

Date of Birth:
Gender FemaleMale

Address
Street:
City:
State
Zip Code:
Phone:

Fun fact about you!

Emergency Contact during event (will be listed on guest's name tag)

Emergency Contact Phone (will be listed on guest's name tag)

Health Concerns

Wheelchair/Accessibility Device Dependent: NoYes
Special Communication Needs: NoYes 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/pollen, etc.)

Food Needs (food cutup or pureed, gluten free, dairy free, etc): NoYes if yes, please explain:

Will Need Medication Administered during event YesNo* 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? YesNo

Will guest be taking public transportation to and from event? YesNo

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

Additional Notes/Concerns You Would Like Us to Be Aware Of

PARENT/CARETAKER INFORMATION

Parent/Caretaker Name(s):

Parent/Caretaker will be… Dropping Guest OffEnjoying Respite Room
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:
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