Night To Shine 2026 Guest Registration - Salem Fields, Fredericksburg, VA

Fill out the form below as/for the guest (age 14 - 110 yrs old)

Your name *

Last name

Email address *

Name as you would like it to appear on Guest Nametag: *

Birthdate *

Gender *

Female

Male

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Phone number *

Phone type

Emergency Contact NAME during event (available if needed - will be on Guest nametag) *

Emergency Contact Phone # during event (will be on Guest nametag) *

Allergies that are only relevant to this event: *

NONE

Dairy

Eggs

Fruit

Gluten

Nuts

Latex (for balloons used in decorations)

Animals (therapy animals may be present)

Other

If any allergies are marked above, please provide additional details (if NONE, write none): *

Food Concerns that are only relevant to this event: *

NONE

Aspiration/Choking/Swallowing Challenges

Celiac Disease

Diabetic food restrictions

Needs assistance with eating

Needs food cut up into small pieces

Portion access/control needed

Parent/caregiver will send guest's food in disposable container

Uses specific eating/drinking utensils (e.g. spoon, straw)

Other

If any food concerns are selected above, please provide additional information (if NONE, write none) e.g. if diabetic, guest may have 1 dessert *

Health Concerns that are relevant to this event: *

NONE

Asthma

Heart concerns

Needs assistance in the restroom (to be provided by parent/caregiver only)

Requires Oxygen

Seizures

Other

If any health concerns, please provide additional information (if NONE, write none) - e.g. guest carries inhaler with him; seizure triggers) *

Special Communication Needs that are only relevant to this event *

NONE

Challenge to understand

Limited expressive vocabulary

Limited receptive vocabulary

Selective mutism

Uses sign language

Uses voice output device

Wears cochlear implants

Other

If any communication needs are selected above, please provide additional information (if NONE, write none) - e.g., key signs, gestures, words, strategies, requires interpreter, etc. *

Sensory Challenges / Concerns *

NONE

Anxiety

Autism

Deaf

Elopement Risk

Loud Noises

Self-Injurious Behavior

Visually Impaired

Needs assistance in dimly lit areas

Other

If any sensory concerns, please provide strategies for successful evening (if NONE, write none) e.g., guest bothered by loud cheering at red carpet entry, needs "quiet clapping" *

Wheelchair / Accessibility Device Dependent: *

NONE

Cane

Gait Belt

Stroller

Walker

Wheelchair

Other

If any mobility concerns are marked above, please provide additional details (if NONE, write none): *

Guest will need to use an accessible van vs limo/party bus DURING the event *

Yes

Medication needs during the Night to Shine event (6:00-9:00pm). **Please note that the church, their staff and volunteers are not allowed to administer medication to guests during the Night to Shine event. *

Please consider adjusting the timing of medication when possible. If it is required during the event, a parent or caretaker MUST be available to administer the medication.

Medication WILL NOT need to be administered during event

Medication WILL need to be administered during event and will make arrangements for this.

Guest would like to request this person to be their Buddy for the event if available:

Respite Lounge *

The respite lounge is a private area where parents/caregivers of guests can relax while remaining onsite during the event; *not accessible to guest party area except with a Volunteer Chaperone who has completed training and background check. However, parents/caregivers are encouraged to go off and enjoy this time away knowing that their guest is taken care of and are having a great time. (Limit of 2 respite attendees per guest; lounge maximum capacity-150 people)

WooHoo! Thanks for the couple hours of "me-time". I will return at 9:00pm for pickup.

I need to be available on-site and will enjoy the Respite Lounge.

Parents/Caregiver Information

Parent/Caregiver Name(s)/Agency: *

Parent/Caregiver E-mail - to be used for all NTS information *

Parent/Caregiver Phone - to be used for all NTS contact *

This is an evening for our honored guests to celebrate and enjoy time with friends. *

For the safety of all guests, if a parent/caregiver needs to physically stay with guest throughout the event, you must register as a Buddy Volunteer and complete the training and background check as required by the Tim Tebow Foundation. Volunteer registration is available at https://salemfields.com/nighttoshine.

I understand and will register as Buddy Volunteer if needed for my guest.

If attending as a part of a group, please include Agency Name, point of contact and phone number.

Media Rights Release

By signing below, and for the good and valuable consideration of participating in an event hosted by Salem Fields Church (SFC) 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 SFC, 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 SFC, 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 SFC, and to any benefits inuring to TTF and SFC as a result of its use of any of the foregoing recordings. Among other things, TTF and SFC 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 CHURCH, for the advancement of TTF and SFC’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and SFC and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and SFC, 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.

As a guest, parent or caregiver, I have read the media rights release and agree and accept *

Agree and Accept

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Salem Fields Church
info@salemfields.com
540-786-6212