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Guest Registration Form for Night to Shine Prom in Sylvester
Please answer each of the following questions for the individual you are registering for Night to Shine. This information will only be used by the event coordinators and any volunteers that will be assisting the individual. **Please complete a separate form for each individual you are registering.**
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* Indicates required question
Email
*
Your email
Participant's Name (First and Last)
*
Your answer
Participant's Birth date
*
MM
/
DD
/
YYYY
Name of Primary Parent/Guardian (First and Last)
*
Your answer
Phone # of Primary Parent/Guardian
*
Your answer
Email for Primary Parent/Guardian
*
Your answer
Name of Secondary Parent/Guardian (First and Last)
Your answer
Phone # of Secondary Parent/Guardian
Your answer
Email of Secondary Parent/Guardian
Your answer
Name of Additional Emergency Contact (First and Last)
*
Your answer
Emergency Contact Phone #
*
Your answer
Participant's Address
*
Your answer
School participant attends and Grade
Your answer
Participant's Disability:
Your answer
Communication:
*
Verbal
Non Verbal
Selective Mutism
Uses communication device or sign language
Other:
Does participant use a wheelchair or walker?
*
Yes
No
Is participant on medication?
*
Yes
No
If applicable, names of medications:
Your answer
Seizures?
*
Yes
No
Please list ALL allergies.
Your answer
Are there any foods/drinks we should not give?
*
Your answer
Is assistance needed with eating/drinking?
*
Your answer
List any specific choking hazards we need to be aware of?
Your answer
Is help needed with toileting? (Adjusting clothing, using restroom, wiping, pullups/diapers, etc.)
*
Your answer
List any specific activities the participant enjoys?
*
Your answer
List any fears the participant have that need to be avoided during event. (Noise, bright lights, police officers, etc.)
Your answer
Describe any behavior concerns you have. (Include what might trigger this behavior and how would you like us to handle it? How can we best comfort them?)
Your answer
All participants will be paired with at least one buddy. Their buddy will have access to their important information and assist them throughout the entire event. Does the participant have a preference in regards to age/gender of their buddy? If so, please explain.
Your answer
Can photographs of the participant be used in relation to the respite event? (May be used in publications, including electronic publications, audiovisual presentations, promotional literature, community presentations, and/or other similar ways.)
*
Yes
No
Include any additional information we should be aware of. (The more we know about the participant the more confident we will be in providing an event that is fun and safe for everyone.)
Your answer
A copy of your responses will be emailed to the address you provided.
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