Night to Shine Guest Registration February 7, 2025

Guest First Name *

Guest Last Name *

Guest Name as you'd like it to appear on your name tag *

Guest Date of Birth XX/XX/XXXX: (Must be 18 or older) *

Gender: *

Male

Female

Address: *

City: *

State: *

Zip Code: *

Guest Email: *

Guest Phone: XXX-XXX-XXXX *

Home Church:

Fun Fact About Guest: *

Emergency Contact During Event (will be listed on Guest's name tag): *

Emergency Contact Phone: XXX-XXX-XXXX (will be listed on Guest's name tag): *

BUDDY INFORMATION:

FWC will assign a Buddy to the guest unless guest is accompanied by a self-identified Buddy. (Please mark one.) *

Guest needs Buddy assigned by FWC.

Guest will be accompanied by group home staff

Guest will be "Buddied" by self-identified Buddy/Caretaker/Family Member/Adult Friend?

Name of Buddy: (Must be 18 or older) ALL BUDDIES MUST REGISTER AS A BUDDY AT www.fwc.life/nts

TRANSPORTATION:

Will Guest be dropped off and picked up by parent/caretaker? (All guests must be picked up by 9:05pm the night of the event.) *

Yes - (Parent/Caretaker must check-in Guest the night of the event.)

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

Yes

Name of Group:

Group Contact Name:

Group Contact Phone:

OTHER INFORMATION:

Health Concerns:

Mobility Needs:

Communication Needs:

Sensory Issues/Concerns:

Allergies:

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

Yes (If yes please explain): Yes (If yes please explain):

Allergies( please list any allergies, food, animals, latex, makeup, plants or pollen etc.):

MEDICATION ADMINISTRATION:

Church personnel, staff and volunteers can not administer 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.

PARENT/CARETAKER INFORMATION:

Parent Caretaker Name: *

Parent/Caretaker Email: *

Parent/Caretaker Phone: XXX-XXX-XXXX *

Parent Caretaker Name:

Parent/Caretaker Email:

Parent/Caretaker Phone: XXX-XXX-XXXX

Parent/Caretaker will be: *

Dropping Guest Off (Must come in and check-in guest)

Enjoying Respite Room* Enjoying 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.

If enjoying Respite Room, how many? Please limit to 2 Parents/Caregivers.

Respite Room - Name:

CARE PROVIDER AGENCY INFORMATION - IF APPLICABLE:

Care Provider Agency (If attending as a part of a group, please include agency or company): You MUST contact Betsy Riffle at (719) 601-6520.

Agency Contact Name:

Agency Contact Email:

Agency Contact Phone: XXX-XXX-XXXX

Will the Agency be sending chaperone(s) to the event?

Yes

No No

Note: Chaperone is not required to stay with guest(s) unless required by care provider Agency)

Will the Chaperone(s) stay with the Guests at the event?

Yes

No No

Will the Chaperone(s) utilize the Respite Room?

Yes

No No

OTHER INFORMATION:

Additional Notes/Concerns You Would Like Us To Be Aware Of:

MEDIA RIGHTS RELEASE:

2025 Family Worship Center Night to Shine Guest/Parent/Caretaker Media Rights Release By signing below, and for the good and valuable consideration of participating in an event hosted by FAMILY WORSHIP CENTER, 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 FAMILY WORSHIP CENTER (“FWC”), a Colorado 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 FWC, 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 FWC, and to any benefits inuring to TTF and FWC as a result of its use of any of the foregoing recordings. Among other things, TTF and FWC 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 FWC, for the advancement of TTF and FWC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and FWC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and FWC, 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. AGREED TO AND ACCEPTED: *

Yes

Name of Parent/Caretaker Name of Parent/Caretaker

IMPORTANT INFORMATION:

PLEASE CHECK CONTACT EMAIL BEGINNING JANUARY 20, 2025 FOR INFORMATIONAL CORRESPONDENCE. Please check your SPAM/TRASH folders.

Guest Tickets will be available beginning February 2, 2025.

Please check your emails for ticket distribution schedule.