Guest Registration

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Ages 14 and Older Welcome

This is an unforgettable celebration event for people with special needs, ages 14 and older.

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Legal First Name *

Last Name *

Preferred First Name (if different from Legal First Name)

Date of Birth * (Must be 14+ years old by date of event)

Gender *

Address *

City *

State *

ZIP Code *

Email Address *

Phone Number *

Caregiver Contact Name During the Event *

Caregiver Contact Phone *

Emergency Contact Name *

Emergency Contact Phone *

Let us know if there is anything we can pray for you about

Additional Notes You Would Like Us to Be Aware Of

Will Need Medication Administered During Event? *

* Please note that the host organization, their staff and volunteers are not responsible for administering medication to guests during the event. If medication is required during the event, a parent or caretaker MUST be available to administer the medication.

Food Needs (food cut-up, gluten free, dairy free, nut free, etc.)? *

Allergies: list any that apply (foods, animals, latex, makeup, plants, pollen, etc.) *

Sensory concerns: (e.g., elopement, strobe lights, camera flashes, loud noises) *

Special communication needs *

Fun fact about your guest *

Wheelchair or accessibility device dependent *

How will the guest be transported? *

First and Last Name of Buddy Request (If possible)

If enjoying Respite Room, please list up to 2 Parents or Caregivers

Name 1

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

Care Provider/Group Agency Information

Will the Guest be with a Group Agency During the Event? *

Media & Liability Release:

(MUST be 18 Years or older) I have read and agree to this waiver. *

By typing your name below you are agreeing to the above. Under 18 requires care provider permission. A care provider must sign below. *

Please review for errors before submitting this form.

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