Night to Shine Guest Registration Form

Guest Registration

Fill out the Guest Registration Form below & click Submit!

Name

Name as you would like it to appear on nametag:

Age/DOB:

Gender:

Male‎ Female‎

Address:

Email

Phone

Fun Fact About You:

Emergency Contact:

Emergency Contact Phone:

Health Concerns:

Wheelchair:

Yes‎ No‎

Special Communication Needs:

No‎ Yes‎

If yes, please explain:

Sensory Issues/Concerns If none please type none. (strobe lights, camera flashes, loud noises, etc.):

Allergies if none please type none. (Please list any that apply: food, latex, makeup, or pollen allergies,etc.):

Food Needs (food cut-up or pureed, gluten free, etc.):

No‎ Yes‎

If yes, please explain:

Parent/Caretaker Information

Parent/Caretaker Name:

Parent/Caretaker Phone:

Parent/Caretaker will be:

Attending Event‎ Dropping Guest Off & Leaving‎

Care Provider Agency Information - If Applicable

Care Provider Agency:

Care Provider Agency Phone:

Agency Chaperone (if applicable):

Additional Notes or Concerns: