Night to Shine 2026 Guest Registration

Immanuel Baptist Church
Friday, February 13, 2026, 6pm-9pm

Looking for the Volunteer Form? Click HERE to Volunteer!

Guest/Participant Basic Information

Please fill-out one form for each guest.

Name

Date of Birth

Gender

Female Male

This address will receive a confirmation email

Phone

On-Site Emergency Contact Name

On-Site Emergency Contact Phone

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

Yes No

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

Yes No

Guest/Participant Health Information (Optional)

We want to make your Night to Shine experience the best it can be. If you are comfortable sharing, please answer the remaining optional items in this section so we can offer the best support.

Will Use and Bring a Wheelchair/Walker? Yes No

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

Potential Behavioral Concerns? (aggression, may run away, etc.)

Any Other Health Concerns?

Special Communication Needs?

Special Food Prep Needs? Cut-up Pureed Gluten-Free Sugar-Free

Other Food Needs/Allergies?

* Please note that the church, 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 it.

Parent/Caretaker Information

Parent/Caretaker Name (If different from emergency contact)

Parent/Caretaker Phone (If different from emergency contact)

Parent/Caretaker Email (If different from emergency contact)

Will parent/caretaker be enjoying the Respite Room?* Yes No

If yes, how many will join you?

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

Care Provider Group/Agency Information (Only for Participants Who Attend with a Group)

Group Home/Agency Name

Group Home/Agency Phone

*We require that you provide at least 1 employee/chaperone for every 3 guests in your group. More help is always appreciated as our number of volunteer "buddies" may be limited.

**Employees/Chaperones will be asked to accompany guests with severe needs throughout the night to provide the best care.

How many Agency Employees/Chaperones will be with your group?

Media Rights Information & Acknowlegement

Please Read First!
*For the safety of our church building and everyone on the property, our church utilizes a 24/7 audio/video surveillance system throughout the inside and outside of our building. This notice is posted on all points of entry. Therefore, everyone who enters our church property will be captured on this system for monitoring and security purposes*

**Additionally, videographers and photographers will be on the property to capture this special night. To protect the participants, the parents/caretakers, and the liability of our church and the Tim Tebow Foundation, you must acknowledge and electronically sign the media release statement below to complete this registration form.

***We realize some participants may not want to be intentionally photographed by our photographers or videographers, and we respect that right. Our solution is to provide a "NO PHOTOGRAPY" label on the participant's name tag if they wish. We will notify the photographer and videographer to avoid capturing them on their cameras.

Media Rights Release & Liability Acknowledgement

By signing below, and for the good and valuable consideration of participating in an event hosted by Immanuel Baptist Church of Benton, Illinois, 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 Immanuel Baptist Church of Benton (“IBC”), an Illinois 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 IBC, 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 IBC, and to any benefits inuring to TTF and IBC as a result of its use of any of the foregoing recordings. Among other things, TTF and IBC 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 IBC, for the advancement of TTF and IBC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and IBC and bind me and my heirs, successors, and assigns.

I, hereby release and discharge and agree to hold harmless TTF and IBC, 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.

I have read and accept the terms.

Agree I would prefer a printable version sent to me instead.

Participant Name & Electronic Signature (If over 18 and able to sign)

Parent/Caretaker/Legal Guardian Name (Electronic Signature)

Today's Date

If you do not want pictures or videos taken, select "Yes" below to receive a "NO PHOTOGRAPHY" label on the participant's name tag.

Do you want a NO PHOTOGRAPHY label? Yes No

Additional Info

Any Additional Notes, Questions, or Concerns?

Night to Shine 2026 Guest Registration

Description

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