Honored Guest Registration Form | Night To Shine at Visalia First – Night To Shine at Visalia First

Honored Guest Registration Form
Guest Information

Name: *
First
Last

If you have a specific Buddy that you would like to be paired with (Chaperone, not your DATE) please enter their name here: They must be registered as a Buddy Volunteer and attend a mandatory training.
First
Last

Name as you would like it to appear on nametag: *

Date Of Birth *

Gender *
Female
Male

Address *
Address Line 1
City
State
Zip Code

Email *

Phone *

Fun Fact About You: *

Emergency Contact During Event:

Emergency Contact Name (will be listed on guest's nametag): *

Emergency Contact Phone (will be listed on guest's nametag): *

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.):

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

Food needs (food cut-up or pureed, gluten free, dairy free, nut free, etc.): *
Yes
No
If your loved one is on a puree diet the parent or caretaker will need to bring that food with them and feed their loved one. Parents/Caretakers are welcome to bring their loved ones dinner if they have a specific request of food or diet. Gluten free options will be provided.

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 the medication.

Will guest be dropped off and picked up by a 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

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

Parent/Caretaker Information:

Parent/Caretaker Name(s) *

Parent/Caretaker Phone *

Parent/Caretaker Email *

Parent/Caretaker will be... *
Dropping Guest Off
Enjoying Respite Room

* If enjoying respite room, how many will be staying? (Respite Room is limited TWO ADULT PARENTS/CAREGIVERS PER GUEST)

1 Adult Caregiver Name:

2nd Adult Caregivers Name:

Care Provider Agency Information – If Applicable

Care Provider Agency (If attending as a part of a group, please include agency or company name):

Care Provider Agency Phone:

Agency Chaperone (if applicable):

Agency Chaperone Cell Phone (Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency. If Chaperone remains with guest, a Background Check will be required.):

Additional Notes or Concerns:

Honored Guest/Parents/Caretakers Media and Liability Rights Release
By signing below, and for the good and valuable consideration of participating in an event hosted by VISALIA FIRST, 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 VISALIA FIRST (“VISALIA FIRST”), a California 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 VISALIA FIRST, 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 VISALIA FIRST, and to any benefits inuring to TTF and VISALIA FIRST as a result of its use of any of the foregoing recordings. Among other things, TTF and VISALIA FIRST 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 VISALIA FIRST, for the advancement of TTF and VISALIA First’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and VISALIA FIRST and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and VISALIA FIRST, 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 California, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions.

I am 18+ and the Honored Guest/Parent/Caretaker and hereby AGREE TO AND ACCEPT the terms of this Media Rights Release: *
I am 18+ and the Honored Guest/Parent/Caretaker and hereby AGREE TO AND ACCEPT the terms of this Media Rights Release:

I, the applicant for this permission form, warrant the truthfulness of the information provided in this application. *Electronic Signature (Please type your first and last name)* *

I understand that checking this box constitutes a legal signature confirming that I acknowledge & agree to the above Terms of Acceptance.

I, the applicant for this permission form, warrant the truthfulness of the information provided in this application. *Electronic Signature (Please use your mouse to sign your first and last name)*

Date: *

Participant Signature: *

Clear Signature

Honored Guest Registration Is Open From 11/1/24 - 1/2/25

Honored Guest Registration Form
Guest Information

Name: *

First

Last

First

Last

Name as you would like it to appear on nametag: *

Date Of Birth *

Gender *

Female
Male

Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

Fun Fact About You: *

Emergency Contact During Event:

Emergency Contact Name (will be listed on guest's nametag): *

Emergency Contact Phone (will be listed on guest's nametag): *

Health Concerns: *

Wheelchair/Accessibility Device Dependent: *

Special Communication Needs: *

If yes, please explain:

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

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

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

If your loved one is on a puree diet the parent or caretaker will need to bring that food with them and feed their loved one. Parents/Caretakers are welcome to bring their loved ones dinner if they have a specific request of food or diet. Gluten free options will be provided.

If yes, please explain:

Will Need Medication Administered During Event: *

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

Will guest be taking public transportation to and from event? *

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

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

Parent/Caretaker Information:

Parent/Caretaker Name(s) *

Parent/Caretaker Phone *

Parent/Caretaker Email *

Parent/Caretaker will be... *

Dropping Guest Off
Enjoying Respite Room

* If enjoying respite room, how many will be staying? (Respite Room is limited TWO ADULT PARENTS/CAREGIVERS PER GUEST)

1 Adult Caregiver Name:

2nd Adult Caregivers Name:

Care Provider Agency Information – If Applicable

Care Provider Agency (If attending as a part of a group, please include agency or company name):

Care Provider Agency Phone:

Agency Chaperone (if applicable):

Agency Chaperone Cell Phone (Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency. If Chaperone remains with guest, a Background Check will be required.):

Additional Notes or Concerns:

I am 18+ and the Honored Guest/Parent/Caretaker and hereby AGREE TO AND ACCEPT the terms of this Media Rights Release: *

I am 18+ and the Honored Guest/Parent/Caretaker and hereby AGREE TO AND ACCEPT the terms of this Media Rights Release:

I, the applicant for this permission form, warrant the truthfulness of the information provided in this application. *Electronic Signature (Please type your first and last name)* *

I understand that checking this box constitutes a legal signature confirming that I acknowledge & agree to the above Terms of Acceptance.

I, the applicant for this permission form, warrant the truthfulness of the information provided in this application. *Electronic Signature (Please use your mouse to sign your first and last name)*

Date: *

Participant Signature: *

Clear Signature