Night to Shine 2023 Registration Form
Please completely fill out and submit this form to register a guest for Night to Shine 2023
Sign in to Google to save your progress. Learn more
First and Last Name *
Name as you would like it to appear on name tag *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Street Address *
City  *
State *
Zip Code *
Fun Fact About You (Guest)
Diagnosis/Health Concerns *
Sensory Issues/Concerns  *
Please list any sensory concerns such as strobe lights, camera flashes, loud noises, etc
Special Communication Needs *
Yes or no. If yes, please explain
Allergies *
Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc) 
Food Needs *
Please list any special food needs. For example, food cut up or pureed, gluten free, dairy free, nut free, etc. 
Will medication need to be administered during the event?  *
Yes or no. If medication is required during the event, either a parent/caretaker must be available to administer it, or meds will need to be turned in to the nurse we will have on site for the evening so that she may administer them. 
Any addition notes/concerns you would like us to be aware of
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bethel Life Worship Center. Report Abuse
Google Forms