Guests Name *

First Name

Last Name

Gender *

Male

Female

is the Guest in a wheel chair? *

Yes!

No

Does the guest have any sensory concerns? *

Keep in mind there will be loud music and possible camera flashes throughout the night.

Yes

No

Parent/Caregiver Name *

First Name

Last Name

Caregivers Phone Number *

(That will be taking the guest to the event)

(###)

###

####

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone Number: *

(###)

###

####

Is the emergency contact connected with a Group Home? *

Yes

No

Media, Photography Consent and Liability Rights Release While attending any aspect of the Night to Shine, you might be randomly selected as an individual or group to be photographed or recorded on video. Please read the full media liability disclosure. This must be agreed upon in order to attend. *

I agree to the Terms and Conditions of the Release