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Copy of Copy of Copy of COMMITTED TO CELEBRATING PEOPLE WITH SPECIAL NEEDS.jpg
Attendee Name *
Attendee Name
Date of Birth *
Date of Birth
Phone *
Phone
Safety Information
Emergency Contact *
Emergency Contact
Emergency Contact Phone *
Emergency Contact Phone
(Optional)
Please list:
(Optional)
Parent/Caretaker Information
Primary Caretaker *
Primary Caretaker
Additional Caretaker
Additional Caretaker
Additional Caretaker
Additional Caretaker
Relationship to Attendee
Primary Caretaker Phone *
Primary Caretaker Phone
Primary Caretaker Will Be *
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.
Care Provider Agency Information - If Applicable
(If attending as part of a group, please include agency or company name)
Care Provider Agency Phone
Care Provider Agency Phone
(If Applicable)
Additional Information
Would you like more information about our Prom Dress Closet? If yes, please include dress size:
Would you be interested in free hair and make-up service?
Tuxedo Referral
Would you like tuxedo referral information?
Anything else you want us to be aware of?
Permission/Authorization Agreement:
Please read the following statements carefully and sign below indicating that you have read and agree to the following: *I have fully disclosed to Horizon Community Church/Night to Shine Prom all pertinent facts about my attendee's special needs and accept full responsibility for failure to do so. *If the attendee is enrolled in the Night to Shine event, I authorize the staff to provide any required special treatment or procedures to them while in their care. I will provide instructions and all supplies for these procedures. *I will supply necessary foods, drinks, snacks, diapers/wipes for attendee. *In case of emergency or accident, I understand that 911/EMS will be called. I authorize EMS to administer any medical treatment, medication or appliance deemed necessary. I also authorize transportation by EMS to the nearest appropriate medical facility as determined by EMS. I understand I will be responsible for payment of all EMS, hospital and physician charges for emergency services to attendee. By typing in your digital signature you are confirming that you have read the above release and agree to it's contents.
Full Name *
Full Name
Date of Signature *
Date of Signature
Night To Shine Participant Media & Liability Rights Release
By signing below, and/or in consideration for participating in an event hosted by, sponsored by, or associated with the Tim Tebow Foundation and Horizon Community Church, I hereby give my full consent to Tim Tebow Foundation, Inc., ("TTF") a nonprofit corporation headquartered in Florida and Horizon Community Church ("HCC"), a CA nonprofit corporation, 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 HCC, 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 HCC, and to any benefits inuring to TTF and HCC as a result of its use of any foregoing recordings. Among other things, TTF and HCC may, but is 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 HCC, for the advancement of TTF and HCC's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and HCC 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 HCC, 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 and 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. I am of full age and have the right to contract in my own name and for each Participant. By typing in your digital signature you are confirming that you have read the above release and agree to it's contents.
Full Name *
Full Name
Date of Signature *
Date of Signature