Night To Shine Honored Guest Form and Waivers

First and Last Name *

Name As It Should Appear On Nametag *

Age/DOB *

Gender *

Male

Female

Address *

Email *

Phone Number *

Fun Fact About You *

Emergency Contact Name *

Emergency Contact Number *

Health Concerns *

Wheelchair/Accessibility Device Dependent: *

Yes

Special Communication Need: 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, dairy free, etc.): *

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. *

Yes

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

Yes

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

Yes

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

Yes

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

Parent/Caretaker Name(s): *

Parent/Caretaker Phone: *

Parent/Caretaker will be… *

Dropping Guest Off

Enjoying 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: (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:

Report abuse