Guest Registration - Night to Shine Midlands

Register for Night to Shine by filling out the form below. If you can’t fill it all out right now, you have the option to save and continue later at the bottom of the form. You will receive an email link to come back later and complete the form. Once you complete and submit the form, you are registered, and you will receive confirmation at the email you registered with. You must complete and submit the form to be registered.

Guest Registration Form

Step 1 of 2

50%

Guest Information

Name(Required)

First Last

Name as you would like it to appear on name tag:(Required)

Age(Required)

Please enter a number from 14 to 99.

Gender

Male

Female

Address

Street Address City State ZIP Code

Email(Required)

Phone(Required)

Church Affiliation?

Fun fact about you

Health Concerns

Wheelchair / Accessibility Device Dependant?

Yes

Special Communication Needs?

Yes

If yes, please explain.

Explain special communication needs

Sensory Issues / Concerns?

Yes

Strobe 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.

Yes

List Allergies

Food Needs?

Food cut-up or pureed, gluten free, etc.

Yes

Explain 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 medication

Yes

How will guest get to and from the event?

Dropped off and picked up by a parent/caretaker

Public transportation

Group that will provide transportation

Emergency Contact Information

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Parent / Caretaker Information

Parent / Caretaker Name(Required)

Parent / Caretaker Phone(Required)

Parent / Caretaker Email(Required)

Parent/Caretaker will be

The 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 Off

Enjoying Respite Room

How many will be enjoying the Respite Room?

Please enter a number from 1 to 6.

Will a Care Provider Agency be involved?

Yes

Care Provider Agency Information

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

Media Release Form

Night 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 Church, 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 Church (“Mt. Horeb Church”), 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 Church, 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 Church, and to any benefits inuring to TTF and Mt. Horeb Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Mt. Horeb Church 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 Church, for the advancement of TTF and Mt. Horeb Church’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Mt. Horeb Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Mt. Horeb Church, 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(Required)

Yes

Comments

This field is for validation purposes and should be left unchanged.