King Street Church at Antrim BIC – Chambersburg, PA

Night to Shine Guest Home Registration 2024 – This is a special form for homes or larger families

Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Name
First Last
Name as you wish it to appear on a name tag:
Gender
- Male
- Female
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone
Emergency Contact Person
First Last
Emergency Contact Phone
Do any guest use a wheelchair? If so, please say who and explain:
Please describe any health concerns: (if so, please say who and what concerns you have)
Are there special communication needs? If so, please say who and some more details about the need.
Please describe any sensory issues/concerns (strobe lights, camera flashes, loud noises, etc). Please note the guests name:
Please describe any guests allergies (food, latex, makeup, plant or pollen allergies, etc). Please note the guests name:
Do you have any special food needs (food cut up or pureed, gluten-free, etc)?
- Yes
- No
Do any of the guest have any special food needs (food cut up or pureed, gluten-free, etc)? Please notes the guest's name:
Each guest will be assigned a "buddy" for the evening. The buddy MAY NOT be another guest, but may be a caretaker. Please note, caretakers will also need to fill out a volunteer registration (signing up to be a buddy) and will need to attend a training session so that they know what to expect at the event. Do you have a buddy you would like to request? If, so please note the guest and buddy name and contact information (email or phone). If you would like a caretaker to be the buddy, please note that also.
Parent/Caretaker's name:
First Last
Parent/Caretaker's phone:
Caretaker's address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Caretaker's email:
The parent/caretaker will be:
- Dropping Guest Off
- Staying On-Site (we will offer a room where a parent/caretaker can wait during the event, but please, only TWO as space is very limited.)
Care Provider Agency (if applicable):

IF attending as part of a group, please include agency or company name.
Care Provider Agency phone (if applicable):
Agency chaperone (if applicable):
First Last
Additional notes or concerns:
NIGHT TO SHINE PARTICIPANT MEDIA & LIABILITY RIGHTS RELEASE: By signing below, and/or by or in consideration for participating in an event hosted by, sponsored by, or associated with the Tim Tebow Foundation and Antrim Brethren in Christ Church/King Street Church, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Antrim Brethren in Christ Church/King Street Church (ABIC/KSC), which are PA nonprofit corporations, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, the actions, physical likeness, biographical information, and/or voice of me and/or any person of whom I am the parent or legal guardian, including minor children (collectively referred to as the “Participants”). Additionally, I hereby grant to TTF and ABIC/KSC, 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 ABIC/KSC, and to any benefits inuring to TTF and ABIC/KSC as a result of its use of any of the foregoing recordings. Among other things, TTF and ABIC/KSC may, but is 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 ABIC/KSC, for the advancement of TTF and ABIC/KSC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and ABIC/KSC and bind the Participants and their heirs, successors, and assigns. I, on behalf of all Participants, hereby release and discharge and agree to hold harmless TTF and ABIC/KSC, 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. The above release applies to both participants and family/caregivers who are staying on-site.
- Check that you have read the release and acknowledge that checking this box constitutes a legal signature confirming that you acknowledge and agree to the above Rights Release.
Signature
Please list today's date for your signature:
MM slash DD slash YYYY
IF CARETAKER IS STAYING ON-SITE, THEY MUST ALSO SIGN
- Check that you, the Caretaker, have read the release and acknowledge that checking this box constitutes a legal signature confirming that you acknowledge and agree to the above Rights Release.
Signature of Caretaker
I understand by checking this box, that I should expect to receive a confirmation email that lets me know I am properly registered. I will watch for this email (check junk box as well) and if I do not receive it within 24 hours of my registration, I will know that my registration may not have transmitted properly. I will contact Mike Dice at michael.dice@gmail.com.
- I understand
By checking this box, I acknowledge that even though King Street Church is the host church, that the event location is at Antrim Brethren in Christ Church (24 Kauffman Rd E, Chambersburg, PA 17202)
- I understand
COMMUNICATIONS RELEASE
- Telephone
- Text Messages
- Email
- Please maintain contact through the parent/guardian only.
- I do not give permission for TTF staff to contact the participant.
I acknowledge TTF staff members and/or volunteers may contact the Participant to discuss their experience at the event, encourage, pray for, or receive general updates. I hereby give my full consent to TTF to contact the Participant after the event directly through the following means: