Night To Shine Guest Registration Step 1 of 3 - Guest Information 33% Name* First Last Age*Gender*MaleFemaleAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Primary/Emergency Contact Name* First Last Relationship To Guest*Emergency Contact Phone Number*Do you have any health concerns?*NoYesWhat are your health concerns?*Special Communication Needs?*NoYesWhat are your Special Communication Needs?*Do you have any sensory issues or concerns?*NoYesWhat are your Sensory Issues/Concerns?*Do you have any allergies?*NoYesPlease list your allergies.*Do you require a therapeutic or specialized diet?*NoYesDietary requirements?*Do you have a dress/suit to wear?*NoYesNight To Shine can provide a suit or dress if necessary.Companion for the eventGuests will be paired with a volunteer companion at the night of the event.If you have someone that you want to be your companion, please enter their name below.Note: This person MUST register as a companion prior to the event. Please have them fill out a volunteer form.Do you have a parent to caretaker attending the event?*NoYesParent/Caretaker/Support Staff InformationParent/Caretaker/Support Staff name(s)* First Last Parent/Caretaker/Support Staff Phone*Parent/Caretaker/Support Staff email* Parent/Caretaker/Support Staff will be: (Select One)*Dropping guest offEnjoying respite room*Accompanying as my companion*The respite room is a private area where parents/caretakers/support staff of guests can spend the evening enjoying food, entertainment and rest while remaining onsite during the event.How may parent/caretakers/support staff will be enjoying the respite room?*Are you attending with a care provider agency?*NoYesCare Provider Agency Information - If ApplicableCare provider agency*What is the name of the care provider agency?Care provider agency phone number*Agency chaperone*(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)How will you be getting home from the event?*Getting picked up at the eventMy caregiver will be attending the eventI am driving myselfAdditional notes or concernsPlease list any questions, notes, or concerns that you may have.Media & Liability Rights Releases* Participant/caretaker/agent agrees to the Media & Liability Rights Releases By registering, you agree to Night to Shine's Participant and Parent/Caretaker Media & Liability Rights Release Forms and Night to Shine's Participant Permission Form: Night to Shine Parent/Caretaker Media Rights ReleaseNight to Shine Parent/Caretaker Media Rights Release By signing below, and for the good and valuable consideration of participating in an event hosted by CHURCH, 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 CHURCH (“CHURCH”), a STATE 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 CHURCH, 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 CHURCH, and to any benefits inuring to TTF and CHURCH as a result of its use of any of the foregoing recordings. Among other things, TTF and CHURCH 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 CHURCH, for the advancement of TTF and CHURCH’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and CHURCH and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and CHURCH, 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.Highland Park Community Church Child Protection PolicyGeneral Purpose Statement Highland Park Community Church seeks to provide a safe and secure environment for the children and youth who participate in our programs and activities. By implementing the below practices, our goal is to protect the children of HPCC from incidents of misconduct or inappropriate behavior while also protecting our staff and volunteers from false accusations. Definitions For purposes of this policy the terms "child", "children" or "youth" include all persons under the age of eighteen (18) years. The terms "staff' or "worker" include both paid and volunteer persons who work with children. For purposes of the Tim Tebow Night to Shine Prom, this includes all prom guests Selection of Workers All persons who desire to work with the children participating in our programs and activities will be screened. This screening includes the following: a) All persons seeking to work with children must complete and sign a written application. The application will inquire into previous experience with children, as well as disclosure of any previous criminal convictions. b) A national criminal background check is required for all employees and for all volunteers working with minors. Two Adult Rule It is our goal that a minimum of two unrelated adult workers will be in attendance at all times when children are being supervised. We do not allow minors to be alone with one adult on our premises or in any sponsored activity unless in a counseling session.Responding to Allegations of Child Abuse Childcare workers may have the opportunity to become aware of abuse or neglect of the children under our care. In the event that an individual involved in the care of children at this church becomes aware of suspected abuse or neglect of a child under his/her care, this should be reported immediately to the Supervisor or Pastor in charge of your ministry for further action including reporting to authorities as is mandated by Wyoming state law.Teenage Workers We recognize that there may be times when it is necessary or desirable for babysitters (paid or volunteer) who are themselves under age 18 to assist in caring for children during programs or activities. The following guidelines apply to teenage workers:a)Must be under the supervision of an adult and must never be left alone with children.Restroom Guidelines For children over the age of five, at least one adult male should take boys to the restroom and at least one adult female should take girls. The worker should then remain outside the bathroom door and escort the children back to the classroom. For the protection of all, workers should never be alone with a child in a bathroom with the door closed and never be in a closed bathroom stall with a child. During the Night to Shine event if a prom attendee needs assistance and their legal guardian is not present then two volunteers of the same gender must be in the restroom at the same time helping the attendee.Accidental Injuries to Children: 1) For minor injuries, scrapes, and bruises, workers will provide First Aid as appropriate and will notify the child's parent or guardian at the time the child is picked up. 2) For injuries requiring medical treatment beyond simple First Aid, the parent and/or guardian will immediately be summoned in addition to the worker's supervisor. If warranted, an ambulance will be called.3) An incident report will be completed in the case of injuries requiring treatment by a medical professional. HPCC CHILD PROTECTION POLICY and TIM TEBOW NIGHT TO SHINE GUEST POLICYVolunteers, return this page to HPCC. Please keep the policy for your referral. I have read and agree to abide by the Highland Park Community Church Child Protection Policy. Name* First Last Signature* This iframe contains the logic required to handle Ajax powered Gravity Forms.