Night to Shine Guest Registration Registration for this year's Night to Shine begins on December 1, 2018. Step 1 of 2 50% Attendee InformationName* First Last Name as you would like it to appear on name tag:*Age*Please enter a number from 14 to 99.GenderMaleFemaleAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Church Affiliation?Fun fact about youHealth ConcernsWheelchair / Accessibility Device Dependant?YesNoSpecial Communication Needs?YesNoIf yes, please explain.Explain special communication needsSensory Issues / Concerns?YesNoStrobe lights, camera flashes, loud noises, etc., please explain.Explain sensory issues.Allergies?If yes, please list any that apply: foods, animals, latex, makeup, plants or pollen, etc. please explain.YesNoList AllergiesFood Needs?Food cut-up or pureed, gluten free, etc.YesNoExplain food needs.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 medicationYesNoWill guest be dropped off and picked up by a parent/caretaker?YesNoWill guest be taking public transportation to and from event?YesNoWill guest be attending as a part of a group that will provide transportation?YesNoEmergency Contact InformationWho should we contact in case of emergency during the event?Contact Name*Contact Phone*Parent / Caretaker InformationParent / Caretaker Name*Parent / Caretaker Phone*Email* Parent/Caretaker will beThe Respite Room is a private area where parents/caretakers of guests can spend the evening enjoying food, entertainment and rest while remaining on-site during the event. Dropping Guest OffEnjoying Respite RoomHow many will be enjoying the Respite Room?Please enter a number from 1 to 6.Will a Care Provider Agency be involved?YesNoCare Provider Agency InformationCare Provider AgencyIf attending as a part of a group, please include agency or company nameCare Provider Agency PhoneAgency ChaperoneIf applicable. Note: Chaperone is not required to stay with guest(s) unless required by Care Provider AgencyAdditional Notes or Concerns Media Release FormNight to Shine Participant Media Rights Release By signing below, and for the good and valuable consideration of participating in an event hosted by Mt. Horeb UMC, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Mt. Horeb UMC (“Mt. Horeb UMC”), a South Carolina nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, my actions, physical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and Mt. Horeb UMC, without royalty or other compensation now or in the future, all rights of every kind and character whatsoever, in perpetuity, in and to any and all such recordings, along with any additional recordings I might provide to TTF and Mt. Horeb UMC, and to any benefits inuring to TTF and Mt. Horeb UMC as a result of its use of any of the foregoing recordings. Among other things, TTF and Mt. Horeb UMC may, but are not required to, copy or reproduce the recording, edit or modify it, incorporate it into another work, display or broadcast it or any of the foregoing privately or publicly, and use or license it or any of the foregoing for use by others, all for the sole benefit and at the sole discretion of TTF and Mt. Horeb UMC, for the advancement of TTF and Mt. Horeb UMC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Mt. Horeb UMC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Mt. Horeb UMC, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recordings or use of recordings. This release shall be construed, interpreted and governed in accordance with the laws of the State of Florida, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I am of full age and have the right to contract in my own name. By clicking YES below you agree and accept this release.I Agree and Accept the Media Release Form* Yes NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
