Night To Shine Guest Registration

Name *
Name
Gender *
Include City, State, and Zip Code
Wheel Chair? *
Special Communication Needs? *
(Please list any that apply: food, latex, makeup, plant or pollen allergies, etc.)
Food Needs (food cut-up or pureed, gluten free, etc.): *
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 onsite during the event.
(If attending as a part of a group, please include agency or company name)
(Note: Chaperone is not required to stay with guest(s) unlless required by Care Provider Agency)