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NIGHT TO SHINE 2018 GUEST REGISTRATION FORM

Name *
Name
Address *
Address
Gender *
Date of Birth *
Date of Birth
Phone *
Phone
Will Need Medication Administered During Event *
*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.
Guest will be dropped off: *
Legal Guardian Information
Name
Name
Phone
Phone
Parent/Caretaker will be...
Address
Address
Emergency Contact Information
Emergency Contact *
Emergency Contact
Emergency Phone *
Emergency Phone
Care Provider Agency Information - If Applicable
(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)

For any questions or information, 

please email cassie.scheuermann@gmail.com 

Or Call: 715-412-0008