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2018 Rhode Island Night to Shine Guest Registration
Join us on Friday, February 9, 2018 from 6-9pm at the Atlantic Resort for a Prom Night you will never forget. Walk the red carpet, enjoy the royal treatment and dance the night away!
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Email
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Your email
First Name:
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Your answer
Last Name:
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Your answer
Name as you would like it to appear on name tag:
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Your answer
Date of Birth:
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MM
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DD
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YYYY
Age:
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Your answer
Gender:
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Female
Male
Address (please include city, state and zip code):
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Your answer
Phone Number:
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Your answer
Fun Fact About You:
Your answer
Emergency Contact during event (NAME):
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Your answer
Emergency Contact Phone Number:
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Your answer
Health Concerns:
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Your answer
Wheelchair / Accessibility Device Dependent:
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Yes
No
Special Communications Needs:
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Yes
No
If you need Special Communications, please explain:
Your answer
Sensory Issues / Concerns (strobe lights, camera flashes, loud noises, etc.):
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Your answer
Allergies (list any that apply: foods, animals, latex, makeup, plants or pollen, etc.):
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Your answer
Food Needs (food cut-up or pureed, gluten-free, etc.):
Your answer
Will need medication administered during event? (Please note that OceanPointe Christian 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.):
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Yes
No
Will guest be dropped off and picked up by a parent/caretaker?:
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Yes
No
Will guest be taking public transportation to and from event?:
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Yes
No
Will guest be attending as part of a group that will provide transportation?:
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Yes
No
Parent / Caretaker Name(s)
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Your answer
Parent / Caretaker Phone Number(s):
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Your answer
Parent / Caretaker will be:
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Dropping guest off
Enjoying Respite Room
How many Parent / Caretakers in your group will enjoy the Respite Room? (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):
Your answer
Care Provider Agency Name:
Your answer
Care Provider Agency Phone Number:
Your answer
Care Provide Agency Chaperone (if applicable - note, chaperone is not required to start with guests unless required by Care Provider Agency):
Your answer
Additional Notes or Concerns:
Your answer
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