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Night to Shine is open to individuals with disabilities ages 14 and up.

Guest Registration Form
As of 1/8/2019-REGISTRATION IS CLOSED
You may still join the wait list by completing the form below and will be notified if an opening becomes available.

* Indicates required field

Name *

First

Last

Name as you would like it to appear on name tag: *

Age/DOB: *

Gender *

Male Female

Phone number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Emergency Contact During Event *

First

Last

Emergency Contact Phone Number *

Fun Fact About You *

Health Concerns *

Wheelchair/Accessibility Device Dependent: *

Yes No

Special Communication Needs *

Yes No

If Yes, Please Explain *

Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.): *

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

Yes No

Alergies *

(Please list any that apply: foods, animals, latex, makeup, plantsor pollen, etc.)

If Yes, Please Explain *

Will Need Medication Administered During Event: *

Yes No

* 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 themedication.

Will guest be dropped off and picked up by a parent/caretaker? *

Yes No

Will guest be attending as a part of a group that will provide transportation? *

Yes No

Parent/Caretaker Information

Name *

First

Last

Parent/Caretaker will be: *

Dropping Guest Off Enjoying Respite Room

If enjoying respite room, how many? *

Phone Number *

* 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.

Care Provider Agency Information – If Applicable

Care Provider Agency *

If attending as a part of a group, please include agency or company name

Agency Chaperone(if applicable): *

First

Last

Phone Number *

Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency.

Additional Notes or Concerns: *

Submit Form

Thank you for checking out Treasure Coast Night to Shine

Telephone

(772) 528-2234
(772) 216-3842

Email

Treasurecoastnighttoshine@gmail.com

Guest Registration FormAs of 1/8/2019-REGISTRATION IS CLOSEDYou may still join the wait list by completing the form below and will be notified if an opening becomes available.

Parent/Caretaker Information

Care Provider Agency Information – If Applicable

Thank you for checking out Treasure Coast Night to Shine

Telephone

Email

Guest Registration Form
As of 1/8/2019-REGISTRATION IS CLOSED
You may still join the wait list by completing the form below and will be notified if an opening becomes available.