Night to Shine Guest Registration Sign up to be an honored guest at Night to Shine of February 9th | 6pm - 9pm Night to Shine Guest Registration Guest * Guest First First Last Last Name as Guest would like it to appear on the nametag. * Guest's Date of Birth (must be at least 14 years of age) * Gender * Male Female Will the guest attend in person or need the Virtual Experience? * In-Person Virtual Guest T-shirt Size (Adult Sizes Only) * XSSMLXL2XL3XL Guest's Address * Guest's Address Guest's Address Guest's Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email * Phone * Fun Fact about Guest * Emergency Contact During Event (will be listed on Guest name tag) * Emergency Contact During Event (will be listed on Guest name tag) First First Last Last Emergency Contact Phone # (will be listed on Guest name tag): * Additional Comments or Notes: Will Guest need Medication Administered During Event? *Please note that Immanuel, 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. * Yes No Will guest be dropped off and picked up by parent/caretaker? * Yes No Will guest be taking public transportation to and from event? * Yes No Will guest be attending as a part of a group that will provide transportation? * Yes No Please answer the following questions to help us address any additional needs. Are there any health concerns? Mobility Needs? Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc) Communication Needs? Allergies (Please list all that apply - food, animals, latex, makeup, etc) Food Needs (food cut up or pureed, gluten free, dairy free, nut free, etc) Any Additional Notes/Concerns of which we should be aware? Caretaker Name(s) * Caretaker Phone Number * Caretaker will be: Dropping Guest Off (and returning at the end of the event) Enjoying Respite Room (a private area where caretakers of guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event) Caretaker Relationship to Guest If enjoying the respite room, please list caretakers (2 maximum per guest). Care Provider Agency Phone Agency Chaperone (if applicable) If applicable, name of Care Provider Agency Agency Chaperone Cell Phone (Note: Chaperone is not required to stay with the guest(s) unless required by Care Provider Agency. If Chaperone remains with guest, a current Background Check will be required. If you are human, leave this field blank. Submit
