LifeSource Community Church

Honored Guest Registration

First Name of Honored Guest

Last Name

Birthdate

Email of Honored Guest

Phone Number of Honored Guest

Address of Honored Guest

Apartment, suite, etc.

City

State

Postal / Zip Code

Gender of Honored Guest

How Will The Honored Guest Arrive To Event?

Parent/Caregiver

Public Transportation

Group Transportation

Honored Guest Personal Info

To make the Night to Shine experience amazing, we would like to support specific needs. If you are comfortable sharing, please answer the following questions.

What name should we put on honored guest name tag?

A Fun Fact About The Honored Guest

Mobility Needs?

Health Concerns?

Communication Needs?

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, nut free, etc.):

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

Medication

Will Medication Be Administered During Event?

Yes

No

Please note that staff and volunteers cannot administering medication to attendees during the Night to Shine event. If medication is required during the event, a parent or caretaker MUST be available to administer the medication.

Emergency Contact Info

Emergency contact name and phone will be printed on guest nametag

First Name

Last Name

Emergency Contact Phone

Parent/Caregiver Info

Is There A Parent/Caregiver For The Night Of The Event?

No

Yes

First Name

Last Name

Phone Number

Caregiver relationship to guest

Parent/Caregiver Staying For Event

Will Parents/Caregivers Be Staying To Enjoy The Respite Room?

No

Yes

* The Respite Room is a private area where caretakers of guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event.

First Name

Last Name

First Name

Last Name

Agency For Guest

Is There An Agency That Provides Care For The Guest?

No

Yes

Agency Name

Agency Phone Number

Chaperone First Name

Chaperone Last Name

Chaperone Phone Number

*A Chaperone is not required to stay with guest(s) unless required by a Care Provider Agency. If Chaperone remains with guest, a current Background Check will be required.)

Media Release

For Night To Shine guests, cartakers and parents: By signing below, and for the good and valuable consideration of participating in an event hosted by LifeSource 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 LifeSource Community Church (“CHURCH”), a Texas nonprofit, 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. (If participant is under age 18, the signature of Parent/Caretaker/Legal Guardian is required below:)
AGREED TO AND ACCEPTED:

Date Input

I agree to sign this form electronically

Thank you for registering with LifeSource Lindale and Night to Shine. If you have questions, please email GrandLove@LifeSourceLindale.com.

Upon Submitting This Form You Will be Redirected to https://lifesourcelindale.quickapp.pro Please complete a background check for all participants STAYING during the event ONLY if you are 18 years of age by 2/7/25

Coming Feb. 7, 2025

Sponsored by the Tim Tebow Foundation

What is Night to Shine?

Honored Guest Registration

Honored Guest Personal Info

To make the Night to Shine experience amazing, we would like to support specific needs. If you are comfortable sharing, please answer the following questions.

Medication

Emergency Contact Info

Parent/Caregiver Info

Parent/Caregiver Staying For Event

Agency For Guest

Media Release

Volunteer Registration

In What Capacity Would You Like to Volunteer?

Night to Shine Participant (Guests, Volunteers & Vendors) Media Rights Release

Allie Pew

What People Are Saying About Night To Shine

Follow Us

Service Times

Business Leaders