Night to Shine Guest Registration

Guest Information

Name

Name as you would like ot to appear on nametag:

Date of Birth

Gender

Female Male

Address

This address will receive a confirmation email

Phone

Fun Fact About you:

Emergency Contact Name During Event (will be listed on guest's nametag)

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

Will Need Medication Administered During Event:

Yes No

*Please note that Friendship 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.

Would you or a member of your family like to be your guests Buddy for the evening?

Yes No

A Buddy will accompany and assist assigned guests throughout the evening. Providing companionship and any assistance they may need during the event. Sit with the guest at dinner, dance with them, and participate in any activities during the evening.

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

Yes No

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

Yes No

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

Yes No

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.

Health Concerns:

Mobility Needs:

Communication Needs:

Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.):

Food Needs: (food cut-up or pureed, gluten free, dairy free, nut free, etc.)

Additional Notes/Concerns You Would Like Us to Be Aware of:

Caretaker Information

Name

Phone

Are you planning to be your guests Buddy?

Yes No

Caretaker will be dropping guest off

Yes No

Caretaker will be enjoying the Respite Room

Yes No

Caretaker Relationship to Guest

If Enjoying the Respite Room*, Please List Caretakers:

*The Respite Room is a private area where the caretakers of the 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) Name

Agency Chaperone Cell Phone

(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency. If Chaperone remains with guest, a current Background Check will be required.)

Additional Notes or Concerns:

Night to Shine Guest Registration

Description

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