Stone Memorial Christian Church - Night Shine Registration

Guest Registration form

(This form MUST be RECIVED by January 31, 2025)

Please download fill and return to our church office or fill out form bellow to register for this year's event.

Guest Information

First Name

Last Name

Name as you would like it to appear on nametag

Age / D.O.B.

Gender
Male
Female

Address 1

Address 2

Country

City

State

Zip/Postal Code

Email Address

Phone Number

Fun Fact about you

Emergency Contact During Event (will be listed on guest's nametag)

Emergency Contact Phone Number (will be listed on guest's nametag)

Health Concerns

Wheelchair/Accessibility Device Dependent
Yes
No

Special Communication Needs
Yes
No

If Yes, Please explain

Sensory Issues/ Concerns (Strobe lights, camera flashes, loud noises, etc.)

Allergies (Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.)

Food Needs (food cut-up or pureed, gluten free, dairy free, etc.)
Yes
No

If Yes, Please explain

Will need Medication Administered During Event
Yes
No

Will guest be dropped off and picked up by a parent/caretaker?
Yes
No

Will guest be taking public transportation to and from event?
Yes
No

Will guest be attending as a part of a group that will provide transportation?
Yes
No

Additional Notes/Concerns You Would Like Us to Be Aware Of

Would you like a Limo Ride
Yes
No

Would you like to to have makeup done
Yes
No

* 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.

Parent/Caretaker Name(s)

Parent/Caretaker Phone:

Parent/Caretaker will be…
Dropping Guest Off
Enjoying Respite Room

If enjoying Respite Room, how many?

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

Care Provider Agency

Care Provider Agency Phone Number

Agency Chaperone (if applicable)

Additional Notes or Concerns:

Submit

Night to shine Parent/Catetaker Media Realease

By signing below. and for the good and valuable consideration of participating in an event hosted by SMCC , 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 Stone Memorial CC , 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, phvsical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and SMCC , 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 SMCC , and to any benefits inuring to TTF and SMCC as a result of its use of any of the foregoing recordings. Among other things, TTF and SMCC 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 SMCC , for the advancement ofTTF and SMCC ’s exempt charitable purposes. All permissions granted herein extend to any successor or assign ofTTF and SMCC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and SMCC , 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 deterrnined 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.

Guest Registration form

(This form MUST be RECIVED by January 31, 2025)

Guest 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.

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

Night to shine Parent/Catetaker Media Realease

Services

Contact Info.

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