top of page

Home
About
Ministries
Guests
"The Why"
Directory Info
Watch
More

Use tab to navigate through the menu items.

(205) 648-2917

WELCOME TO BETHEL

Participant Registration Form

Guest Information

First Name

Last Name

Name as you would like it to appear on nametag

Date of Birth

Gender

Female

Male

Address

City

State

Zip Code

Email

Phone

Fun Fact About You:

Emergency Contact during event (will be listed on guest's nametag)

Emergency Contact Phone Number (will be listed on guest's nametag)

Health Concerns

Wheelchair/Accessibility Device Dependent

Yes

No

Special Communication Needs

Yes

No

If yes, please explain

Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.)

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

Food Needs (food cut-up or pureed, gluten free, dairy free, nut free, etc.)

Yes

No

If yes, please explain

Will Need Medication Administered During Event

Yes

No

* 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 medication.

Will guest be dropped off and picked up by a parent/caretaker?

Yes

No

Will guest be taking public transportation to and from event?

Yes

No

Will guest be attending as a part of a group that will provide transportation?

Yes

No

Additional Notes/Concerns You Would Like Us to Be Aware Of

Parent/Caretaker Information

Parent/Caretaker Name(s)

Parent/Caretaker Phone Number

Parent/Caretaker will be...

Dropping Guest Off

Enjoying Respite Room*

If enjoying Respite Room, please limit to two Parents or Caretakers.

Name 1

Name 2

* 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

Care Provider Agency

If attending as a part of a group, please include agency or company name.

Care Provider Agency Phone Number

Agency Chaperone (if applicable)

Agency Chaperone Cell Phone

Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency. If Chaperone remains with guest, a Background Check will be required.

Additional Notes/Concerns

Thank you for registering for Night To Shine. See you there!

(205) 648-2917

7000 Bethel Rd, Dora, AL 35062, USA

©2022 by Bethel Baptist Church.

bottom of page