Name you would like on your name tag:

Date of Birth:

Address

Include City, State, and Zip Code

Email Address

Phone

Fun Fact About You:

Emergency Contact during event (will be listed on guest’s nametag):

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

Medical Diagnosis:

Health Concerns:

If yes, please explain:

Sensory Issues or Concerns:

Allergies:

Parent/Caretaker Name(s)

Parent/Caretaker Phone:

If enjoying Respite Room, please limit to two Parents or Caretakers.

* 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 Information – If Applicable

Care Provider Agency Phone:

Text Agency Chaperone (if applicable):

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 Background Check will be required.)

Additional Notes or Concerns:

Night To Shine 2023 Guest Registration