Guests MUST be 14 years old or older ~ Register early, space is limited!

February 8. 2019 | Please fill out this form with as much information as possible and click submit.
NOTE: Care Provider Agencies... Please contact NTS.Sheb.County@gmail.com for GROUP REGISTRATIONS

2019 NIGHT TO SHINE INDIVIDUAL GUEST APPLICATION

Help us get to know you better by completing as much information as possible because we're preparing an unforgettable experience for you...
 
 
 
 
 
 
We need a current photo for your nametag. Please submit one to us as soon as possible via email (preferred) or regular mail: CLC 300 Rustic Street, Plymouth, WI 53073 ATTN: Night to Shine - THIS IS A VERY IMPORTANT STEP - Thank you!
 
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Accessibility & Health Concerns

 
 
 
 
*If medication is required during the event, a Parent/Caretaker MUST be available to administeer the medication. Christian Life Church, Salem UCC Plymouth, St. Paul Lutheran Church Sheboygan Falls, their staff and volunteers are not responsible for administering medication to guest during the Night to Shine event.
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Emergency Contact Information for February 8, 2019

 
 
 
 
 
 
Parent/Caregiver Information

The prom is a special experience for the Guests.

Parents, Relatives, & Caregivers of the Guest are encouraged to view the King's & Queen's Red Carpet entrance and annoucement, take pictures with the paparazzi, and cheer with the crowd.

The Respite Room is a private area where Parents/Caregivers of the guest may spend some of the evening enjoying food, entertainment, and rest while remaining onsite during the event.
Parent/Caregiver Name(s) and Phone

 
 
 
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Care Provider Agency Information - If Applicable

 
 
 
 
 
(NOTE: Lead Staff/Chaperone is not required to stay with Guest(s) unless required by Agency)
 
 
 
 
Media & Liability Release

ATTENTION PARTICIPANT, PARENT/GUARDIAN, CAREGIVER - Please read the following Participant & Parent/Caregiver Media & Liability Rights Release carefully. If you have questions about it, ask before you sign it. A signed Participant & Parent/Caregiver Media & Liability Rights Release is required for anyone desiring to participate in Night To Shine Sheboygan County on February 8, 2019. This participant application cannot be processed without it.
Participant & Parent/Caregiver Media & Liability Rights Release for February 8, 2019

By signing below, and for the good and valuable consideration of participating in an event hosted by Christian Life Church Plymouth ("CLC"), Salem UCC Plymouth ("Salem"), and St. Paul Lutheran Church Sheboygan Falls ("SPF"), 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 CLC, Salem, and SPF, Wisconsin nonprofit organizations, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, the actions, physical likeness, biographical information, and/or voice of me and/or any person of whom I am the parent or legal guardian, including minor children (collectively referred to as the “Participants”). Additionally, I hereby grant to TTF and CLC, Salem, and SPF, 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 CLC, Salem, and SPF, and to any benefits inuring to TTF and CLC, Salem, and SPF as a result of its use of any of the foregoing recordings. Among other things, TTF and CLC, Salem, and SPF 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 CLC, Salem, and SPF, for the advancement of TTF and CLC, Salem, and SPF’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and CLC, Salem, and SPF, and bind the Participants and their heirs, successors, and assigns. I, on behalf of all Participants, hereby release and discharge and agree to hold harmless TTF and CLC, Salem, and SPF, 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 recording or use of the 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.
BY TYPING YOUR NAME, CHECKING THE ELECTRONIC SIGNATURE BOX, & SUBMITTING THIS FORM, YOU ARE INDICATING THAT THE ABOVE LISTED "PARTICIPANT & PARENT/CAREGIVER MEDIA & LIABILITY RIGHTS RELEASE" IS UNDERSTOOD, AGREED TO, AND ACCEPTED BY THE PARTICIPANT NAMED IN THIS FORM.
 
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BY TYPING YOUR NAME, CHECKING THE ELECTRONIC SIGNATURE BOX, & SUBMITTING THIS FORM, YOU ARE INDICATING THAT THE ABOVE LISTED "PARTICIPANT & PARENT/CAREGIVER MEDIA & LIABILITY RIGHTS RELEASE" IS UNDERSTOOD, AGREED TO, AND ACCEPTED BY THE PARENT/GUARDIAN/CAREGIVER NAMED IN THIS FORM.
 
 
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What to expect next...
Immediately after you click "submit" you will be sent to a confirmation page and a confirmaton email will be sent. 

Thank you!

Night To Shine Sheboygan County Administrative Team

Description

February 8. 2019
Please fill out this form with as much information as possible and click submit.