Attend Night to Shine | Willamette Christian Church

Guest Information

Guest Name

First Name

Last Name

Name as you would like it to appear on nametag

Date of Birth

Gender

Female

Male

Other/decline to state

Email

Address

Street Address (or PO Box)

City

ZIP Code

State

Fun Fact About You

Emergency Contact During Event

Will be listed on guest’s nametag

Emergency Contact Phone

Will be listed on guest’s nametag

Guest Transportation

Parent/guardian will provide transportation

Guest will be attending as a part of a group that will provide transportation

Other

Please Explain:

Guest Accommodations

Health concerns

Wheelchair/accessibility device dependent?

No

Yes

Special communication needs?

No

Yes

Please explain:

Sensory issues/concerns

Such as strobe lights, camera flashes, loud noises, etc.

Allergies

Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.

Any special food needs?

Food cut-up or pureed, gluten-free, dairy-free, nut-free, etc.

No

Yes

Please explain:

Will guest need medication administered during event?

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.

No

Yes

Any additional notes/concerns we should be aware of?

Parent/Caretaker Information

Parent/Guardian/Caretaker Name(s):

Parent/Guardian/Caretaker Phone:

Parent/Guardian/Caretaker Will:

Drop guest off

Enjoy Respite Room

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.

Please limit to two Parents/Guardians/Caretakers:

Parent/Guardian/Caretaker 1

First Name

Last Name

Parent/Guardian/Caretaker 2

First Name

Last Name

Care Provider Agency Information

Name of care provider agency

Care provider agency phone

Agency chaperone

First Name

Last Name

Agency chaperone's cell phone

Chaperone:

Will drop guests off

Enjoy Respite Room

Is required by care agency to stay inside event space with guests

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.

Please fill out the additional fields below so that we can request that a background check be run.

Chaperone's date of birth

Chaperone's email address

Media Releases

A signed media release is required for all event attendees, including guests and any parents/guardians/caretakers who will remain on the premises. A parent/guardian must sign on behalf of any guests who are under 18.

By entering my name below, and for the good and valuable consideration of participating in an event hosted by Willamette Christian Church, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Willamette Christian Church (“WCC”), an Oregon nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, my actions, physical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and WCC, 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 TTF and WCC, and to any benefits inuring to TTF and WCC as a result of its use of any of the foregoing recordings. Among other things, TTF and WCC may, but are 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 TTF and WCC, for the advancement of TTF and WCC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and WCC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and WCC, 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 recordings or use of 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.

Night to Shine Guest

Name of participant

Name of parent/guardian if participant is under 18

Onsite Parent/Guardian/Caretaker

Name of parent/guardian/caretaker