Night to Shine Guest Registration

Participant Name *

Age of Participant (Must be 14 years or older) *

Phone Number

Parent/Guardian Name *

Parent/Guardian Phone *

Email Address of Parent or Guardian *

Name as you would like it to appear on name tag *

Street Address *

City *

State *

Zip Code *

Emergency Contact and Phone Number (During Event) *

Special Healthcare Needs or Concerns (Please check all that apply)

Wheelchair/Accessibility Device Dependent

Special Communication Needs

Sensory Issues or Concerns (strobe lights, camera flashes, loud noises, etc.)

Allergies (foods, latex, makeup, etc.)

Food Needs (food cut-up, pureed, gluten free, etc.)

Please explain

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Will Parent/Guardian be *

dropping guest off

remaining with guest

enjoying respite area (for parents/ guardians with food , entertainment, etc.)

If enjoying respite room, how many? (maximum of 2)

If attending with an agency please provide chaperone's name and phone number

Additional notes or concerns

Night to Shine Parent/Caretaker Media Rights Release
By signing below, and for the good and valuable consideration of participating in an event
hosted by Grace Community 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 Grace Community 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 Grace Community 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
Grace Community Church, and to any benefits inuring to TTF and Grace Community Church as a result of its use of any of the
foregoing recordings. Among other things, TTF and Grace Community 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
Grace Community Church, for the advancement of TTF and Grace Community Church’s exempt charitable purposes. All
permissions granted herein extend to any successor or assign of TTF and Grace Community Church and bind me
and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold
harmless TTF and Grace Community 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.
AGREED TO AND ACCEPTED:

By typing your name here, you are signing this form electronically *

Each guest will be assigned a Buddy to accompany them during the entire evening. But, please note that the church, 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. *By typing your name below you have read and agreed to the above information. *