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Guest Information:

For guests with special needs ages 14 and older. Registration deadline is January 18, 2019
Name *
Name
Gender *
Address *
Address
Phone *
Phone
Emergency Contact Phone: *
Emergency Contact Phone:
Wheelchair/Accessibility Device Dependant:
Special Communication Needs:
Tip: Please list any that apply: foods, animals, latex, makeup, plants or pollen, etc.
Food Needs:
Tip: (food cut-up, or pureed, gluten free, etc.)
Will Need Medication Administered During Event
Tip: Please note that Eastside, 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.
Will guest be taking public transportation to and from this event?
Will guest be attending as part of a group that will provide transportation?
Parent/Caretaker Information. If guest lives in a group home, skip to Care Provider Agency Information.
Tip: Please provide for sharing information and parent respite.
Parent/Caretaker will be...
If enjoying Respite Room, how many?
Tip: 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.
Guest- Buddy Pairing: A buddy will be provided by our Night to Shine staff for you. It is our goal at Night to Shine to provide a full night of fun and respite for all guest and their families. Our staff is prepared to match your needs with a registered volunteer buddy. If you request a specific person to be your buddy, that individual MUST complete the volunteer registartion form on this event page. If they do not complete the volunteer registration, they will not be permitted to enter the event.
Care Provider Agency Information- if Applicable
Tip: If attending as a part of a group, please include agency or company name.
Tip: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency
ECC LIABILITY RELEASE FORM- I, the undersigned, desire to voluntarily participate in the 2019 Night to Shine (the “Program”), sponsored by The Tim Tebow Foundation (The Sponsor) and hosted by Eastside Christian Church (“The Church”). I acknowledge that such Program may be hazardous and I hereby assume all responsibility and risk for any accidents, sickness, or other mishaps, including, but not limited to, serious bodily injury, permanent disability, and/or death, that may result to me on the Program. In connection with my participation in the Program, I hereby waive my rights to any claim, cause of action, and/or the right to file a law suit against The Sponsor and The Church, or against any of its affiliates, parent organizations, directors, officers, sponsors, employees, agents, volunteers, successors and assigns. I further release all such organizations and/or persons from any and all responsibility or liability of any nature whatsoever for any loss or damage to my person or property, including, but not limited to, personal injury and/or death sustained on or through the Program. This Waiver and Release of Liability is binding upon my personal representatives, trustees, heirs, successors, beneficiaries, relatives, next of kin or assigns and shall inure to the benefit of all organizations named herein as well as to their directors, officers, sponsors, employees, agents, volunteers, successors and assigns. If any provision of this document is held to be invalid or unenforceable, this form shall be construed as if the invalid or unenforceable provision was not contained in the document. I have carefully read this General Liability Release. By my signature, I am stating that I understand, agree to, and accept all of its provisions, and understand that I am giving away substantial legal rights. Participant may be guests, volunteers, parents/caretakers.
AGREED TO AND ACCEPTED
NIGHT TO SHINE PARTICIPANT/PARENT/CARETAKER MEDIA RIGHTS RELEASE By signing below, and for the good and valuable consideration of participating in an event hosted by Eastside Christian Church, and sponsored in part by or associated with the Tim Tebow Foundation, I herby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Eastside Christian Church (“ECC”), an Indiana 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 ECC, 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 ECC, and to any benefits inuring to TTF and ECC as a result of its use of any of the foregoing recordings. Among other things, TTF and ECC 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 ECC, for the advancement of TTF and ECC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and ECC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and ECC, its director, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamations 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.
Media Rights Release *