Night to Shine Guest Registration
* First Name
* Last Name
* Email
* Mobile Phone
* Street Address
* State/Zip
* Age
* Gender
Female
Male
* Emergency Contact Phone #
* Dietary Restrictions
* Food Needs (ex. food cut up, pureed, gluten free, thickened liquids, no meal)
Select one
Yes
No
* If yes, please explain
* Wheel Chair
Select one
Yes
No
* Health Concerns
* Allergies (Please list any that apply: food, latex, makeup, perfume, plant, or pollen allergies, etc)
* Special Needs: Night to shine is a high energy promo event which includes loud music, cheering and many guests. Please list below any sensory/behavioral concerns that you may have for your guest. We would like toa ssign them to a buddy with appropraite expertise
* The Red Carpet will involve cheering and clapping. A private entrace will be available to accomdoate sensory needs. Please indicate whether you need this accomdation?
Select one
Yes
No
Possibly
* Special Communication Needs?
Select one
Yes
No
* If yes, please explain (ASL, non-verbal, communication device, gestures, etc)
* If yes, please explain:
* Fun Fact About You
* Buddy Preference (we will do our best to honor your request)
Select one
Male
Female
No Preference
Attend w/family member or caretaker who will serve as Buddy
* If you have chosen "Family Member or caretaker who will serve as Buddy" please supply their name and contact number.
* Would you like to sit with someone in particular for dinner? (We will do our best to honor your request)
Select one
Yes
No
* If Yes, Please supply their name below
* Caretaker name, if other than parent
* Parent/Caretaker phone
* Parent/Caretakers have the opportunity to enjoy the respite room which includes a catered meal, live stream, and raffle drawings, all of which will be free of charge. We encourage all parents and caregivers to stay in the room for the duration of the event. Please limit parents and caregivers to 2 per guest.
Select one
Dropping Guest Off
Caregiver will stay with Guest as a buddy
Utilizing Respite Room
* How many caregivers/family members will be utilizing respite room?
Select one
0
1
2
* How did you hear about this event?
* Do you have a home church?
Select one
Yes
No
* If yes, where do you Attend?
* What additional information do we need to know about the guest?
Add Another Person
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