Night to Shine Guest Registration

Guest Name

This address will receive a confirmation email

Phone

Date of Birth (MM/DD/YYYY)

Gender

Male Female

Emergency Contact Name

Emergency Contact Phone #

UnnamedEmergency Contact Relationship to Guest

Are there any Health Concerns

Yes No

If Yes, Please Explain

Wheelchair or Device Dependent?

Yes No

If Yes, Please Explain

Are there any sensory issues?

Yes No

If Yes, Please Explain

Allergies?

Yes No

Please List Allergies

Please Read our policy regarding administering medication.

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.

By checking the box, I understand the policy regarding administering medication..

I Understand

Is the Honored Guest a part of a Care Provider Agency?

Yes No

If yes, name the agency

Please provide the phone number of Care Provider Agency.

Respite Room

If you are a parent or caretaker, we want to invite you to our Respite Room — a private area where parents/caretakers of guests can spend the evening enjoying food, entertainment and rest while remaining onsite during the event.

Choose One

I would like to participate in the Respite Room I Want to Volunteer for Night to Shine I will not be on site during event.

If you are wanting to be a Buddy or other volunteer position, please fill out our volunteer registration.

Night to Shine Media Rights Release

I hereby give my full consent to Tim Tebow Foundation, Inc., ("TIF") a nonprofit corporation headquartered in Florida and ABC, a Texas nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, the actions, physical likeness, biographical information, and/or voice of me and/or any person of whom I am the parent or legal guardian, including minor children (collectively referred to as the ”Participants").

Additionally, I hereby grant to TIF and ABC, 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 TIF and ABC, and to any benefits inuring to TIF and ABC as a result of its use of any of the foregoing recordings. Among other things, TIF and ABC may, but is 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 TIF and CHURCH, for the advancement of TIF and ABC's exempt charitable purposes.

All permissions granted herein extend to any successor or assign of TIF and ABC and bind the Participants and their heirs, successors, and assigns. I, on behalf of all Participants, hereby release and discharge and agree to hold harmless TIF and ABC, 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 recording or use of the 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 and for each Participant.

By checking the box, I agree to the Night to Shine Media Rights Release

I Agree

Night to Shine Guest Registration

Description

Please Fix the Following