See below for the registration!

See below for the registration!

Guest Name *
Guest Name
Phone Number *
Phone Number
Emergency Contact Name *
Emergency Contact Name
What is your (guest) gender?
What gender would you like your buddy to be?
We will try our best to accommodate your request.
What is your birthday? *
What is your birthday?
What is your address?
What is your address?
Do you need an interpreter? *
Please tell us of any allergies, special needs, or anything we should know.
Do you tend to have an elopement behavior? *
Elopement behavior occurs when an individual runs or wanders from a safe, supervised environment. So does the guest tend to wander off without informing individuals?
Are there any sensory issues that we should be aware of? *
Strobe lights, camera flashes, loud noises, etc.
Will you have a nurse/aide attending with you? *
If a nurse/aide will be attending, what is his/her name?
If a nurse/aide will be attending, what is his/her name?
Examples: Connection, Palm Tran, Parent/Guardian, Uber, Lyft
Parent/Caretaker Name
Parent/Caretaker Name
Parent/Caretaker Phone Number
Parent/Caretaker Phone Number
Phone Number of Contact at Care Provider Agency - If Applicable
Phone Number of Contact at Care Provider Agency - If Applicable
Please Check Yes that you understand the volunteers/staff at UMCPB for Night to Shine 2020 are not responsible for administering medication to guests during the Night to Shine event. A parent/caretaker must be available to administer medication, if necessary. *