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REGISTRATION IS CURRENTLY FULL, ALL APPLICATIONS SUBMITTED AFTER JANUARY 12 WILL BE PLACED ON A WAITLIST

* 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.

Parent/Caretaker Information

* 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

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

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

By submitting this form, you are consenting to waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

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