register to be our special guest Guest's Name * First Name Last Name Date of Birth * MM DD YYYY Gender * Male Female Prefer not to say Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Emergency contact during event (will be listed on guest’s name tag) * Will guest be dropped off and picked up by parent/caretaker * Yes No Will guest be taking public transportation to and from event? * Yes No Will guest be attending as part of a group that is providing transportation? * Yes No Will medication need to be administered during event? * * Please note that the church, 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. Yes No Does guest have dietary needs? Gluten free Dairy free Nut free Other - please make note below Is guest interested in any bonus services? Bonus services will be provided between 5:30-6:30 PM on February 13, 2026. Hair Make-up Nails Is guest interested in visiting the Night to Shine formal wear boutique in January? Both men and women's formal wear will be available for your choosing. Additional details to come. Yes No T-Shirt Size * Adult Sizes Small Medium Large X-Large XX-Large Fun Fact About Guest WE WOULD LOVE TO MAKE THE NIGHT TO SHINE EXPERIENCE THE BEST IT CAN POSSIBLY BE. If comfortable sharing, please answer any of the following optional items that apply in order to help us offer the best support we can. Health Concerns Mobility Needs Communication Needs Allergies Additional Food Needs (Should food be cut up, smashed, etc.? Are there other dietary restrictions?) CARETAKER INFORMATION Caretaker Name * First Name Last Name Caretaker's Phone * (###) ### #### Character relationship to guest * Caretaker will be ... * Dropping guest off Enjoying Respite Room (* The Respite Room is a private area where caretakers of guests can spend the evening enjoying food, entertainment, and rest while remaining onsite during the event) Accompanying guest throughout the night Care Provider Agency (if applicable) (If attending as a part of a group, please include agency or company name) Care Provider Agency Phone (if applicable) (###) ### #### Additional notes or concerns NIGHT TO SHINE PARTICIPANT MEDIA RIGHTS RELEASE FOR PARTICIPANTS OVER AGE 18: By checking below, and for the good and valuable consideration of participating in an event hosted by Bedrock Lynchburg, 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 Bedrock Lynchburg (Bedrock) and Waymaker Church (Waymaker), a Virginia 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 Bedrock Lynchburg and Waymaker Church, 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 Bedrock Lynchburg and Waymaker Church, and to any benefits inuring to TTF and Bedrock Lynchburg and Waymaker Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Bedrock Lynchburg and Waymaker Church 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 Bedrock Lynchburg and Waymaker Church, for the advancement of TTF and Bedrock Lynchburg and and Waymaker Church's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Bedrock Lynchburg and Waymaker Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Bedrock Lynchburg and Waymaker Church, 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 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. * Agree Disagree (note: formal photos and photo booth station photos will not be taken by Night to Shine photographers) Participant is under age 18 - see below If participant is under age 18 - Parent/Caretaker/Legal Guardian Consent Agree Disagree (note: formal photos and photo booth station photos will not be taken by Night to Shine photographers) NIGHT TO SHINE PARENT/CARETAKER/LEGAL GUARDIAN MEDIA RIGHTS RELEASE By checking below, and for the good and valuable consideration of participating in an event hosted by Bedrock Lynchburg, 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 Bedrock Lynchburg (Bedrock) and Waymaker Church (Waymaker), a Virginia 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 Bedrock Lynchburg and Waymaker Church, 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 Bedrock Lynchburg and Waymaker Church, and to any benefits inuring to TTF and Bedrock Lynchburg and Waymaker Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Bedrock Lynchburg and Waymaker Church 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 Bedrock Lynchburg and Waymaker Church, for the advancement of TTF and Bedrock Lynchburg and and Waymaker Church's exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Bedrock Lynchburg and Waymaker Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Bedrock Lynchburg and Waymaker Church, 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 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. Agree Thank you for registering for Night to Shine Lynchburg area! Your registration has been received.We are so excited to share in this event with you! Additional details will be sent closer to the event.- Night to Shine Lynchburg area
