Night To Shine Guest Registration

Night to Shine is an unforgettable prom night experience, centered on God’s love, for people with special needs, ages 14 and older.  We are so excited to honor each of our guests with this amazing evening!  Please provide the following information to register the person attending the event.

Event Timing: February 9, 2024
Event Address:  63 Broad St, Plattsburgh, NY 12901
Contact us at ntsplattsburgh@gmail.com
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First Name *
Last Name *
Does the guest have a preferred name or nickname we should use on their name tag and for the evening? 
Age as of 2/9/2024 *
Gender *
Address *
Provide mailing address if different.
Email
Phone Number
Fun Fact About The Guest
Guest's Disability: *
Please list any specific food needs, health conditions, allergies, or dietary restrictions of this guest: 
Example: Food cut-up or pureed, gluten free, diabetic etc. If none enter "None". 
 *
Please list any guest precautions, restrictions, or behaviors you feel should be noted. Are there any effective strategies or procedures that would be helpful in working with the guest? *
Special Communication Needs: *
Does the guest require the use of any adaptive equipment?  *
Required
Are there any activity limitations we should know about in order to safely and successfully work with this honored guest? Please be specific. *
Please indicate which entrance type would best suit the guest.
Two different entrance experiences are provided so each guest may enter in the way most that is most comfortable for them.
 *
Karaoke Song Request:
Please provide your mailing address if it is different from above
I understand that Plattsburgh House of Prayer, 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. *
Is there anything we can be praying about for you or your guest?
Additional notes/concerns you would like us to be aware of?
Parent/Caretaker Names *
Parent/Caretaker Cell Number *
Parent/Caretaker Email
Care Provider Agency (If registering as a part of a group, please include agency or company name).
Care Provider Agency Phone
Agency Chaperone (If applicable)
Agency Chaperone Cell Phone
Night to Shine Participant (Guests & Volunteers)
Media Rights Release By signing below, and for the good and valuable consideration of participating in an event hosted by Plattsburgh House of Prayer (PHOP), 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 Plattsburgh House of Prayer (PHOP), a New York 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 PHOP, 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 PHOP, and to any benefits inuring to TTF and PHOP as a result of its use of any of the foregoing recordings. Among other things, TTF and PHOP 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 PHOP, for the advancement of TTF and PHOP’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and PHOP and bind me
and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and PHOP, 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.
 *
Age *
Name of Guest/Participant *
Name of Adult (if person above is under 18 yrs of age) By typing your name below you are agreeing to the above.  Under 18 requires parent/guardian  permission. ***Parent/guardian must sign below.
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