Quad City Night To Shine
Quad City Night To Shine

Guest Registration for Quad Cities Night To Shine at Tax Slayer Center

** You are about to Register as a GUEST for the Night To Shine Prom Event at the Tax Slayer Center, 1201 River Drive, Moline, Illinois on February 8th, 2019 from 6:00 to 9:00 PM.  Guest check-in will start at 5:30 PM** 

Do you utilize a wheelchair *
Name *
Name
Address *
Address
Phone
Phone
Additional Phone
Additional Phone
What is your gender?
Limo rides are short rides throughout the evening so that our guests can enjoy the experience of riding in a limousine.
Would you like to participate in a limo ride? *
A Buddy is someone who will accompany you during the prom event. We plan to have a Buddy for each guest. If you are bringing your own Buddy, we ask that they register as a VOLUNTEER! We prefer to provide a Buddy unless special care is needed for the guest. Please choose one of the following
Do you have a Buddy? *
If you answered that you will have your own buddy, please list their name, email and phone number in the text box below. Buddies should only accompany one quest. And please remember they must REGISTER as a VOLUNTEER!
Any special needs that we should be aware of? e.g. Special communications needs, any sensory issues/concerns, any required food preparation, any allergies to food or other items (e.g. latex, make-up, pets)
Emergency Contact During the Event - Name *
Emergency Contact During the Event - Name
Emergency Contact - Phone *
Emergency Contact - Phone
If attending as part of a group, please include agency or company name, phone number, and if an agency chaperone is attending the event (include name and phone number of chaperone). (Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency)
Parent/Caregiver Name *
Parent/Caregiver Name
Parent/Caregiver Phone *
Parent/Caregiver Phone
A respite room will be available for parents and caregivers. Will your parent/caregiver utilize this room during the evening? *(The Respite Room is a private area where parents/caregivers of guests can spend the evening enjoying food, entertainment and rest while remaining onsite during the event.)
Respite Room *
Media and Liability Release
NIGHT TO SHINE MEDIA AND LIABILITY RIGHTS RELEASE - PARENT/CAREGIVER *
By clicking “Yes I agree” below, and for the good and valuable consideration of participating in an event hosted by Risen Christ Lutheran Church or Our Lady of the River Catholic Church (“RCLC or OLOR”), 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 RCLC or OLOR, an Iowa 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 RCLC or OLOR, 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 RCLC or OLOR, and to any benefits inuring to TTF and RCLC or OLOR as a result of its use of any of the foregoing recordings. Among other things, TTF and RCLC or OLOR 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 RCLC or OLOR, for the advancement of TTF and RCLC or OLOR’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and RCLC or OLOR and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and RCLC or OLOR, 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 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.
NIGHT TO SHINE MEDIA AND LIABILITY RIGHTS RELEASE - PARTICIPANT *
By clicking “Yes I agree” below, and for the good and valuable consideration of participating in an event hosted by Risen Christ Lutheran Church or Our Lady of the River Catholic Church (“RCLC or OLOR”), 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 RCLC or OLOR, an Iowa 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 RCLC or OLOR, 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 RCLC or OLOR, and to any benefits inuring to TTF and RCLC or OLOR as a result of its use of any of the foregoing recordings. Among other things, TTF and RCLC or OLOR 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 RCLC or OLOR, for the advancement of TTF and RCLC or OLOR’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and RCLC or OLOR and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and RCLC or OLOR, 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 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.