Register for Dickson City Guest InformationName* First Last Name as you would like it to appear on nametag.Date of Birth* Gender*MaleFemaleAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone*Fun Fact About YouEmergency Contact*Emergency Contact Phone*Health ConcernsWheelchair*YesNoSpecial Communications Needs*NoYesPlease explain any Special Communications needs.Sensory Issues/Concerns (strobe lights, camera flashes, loud noises, etc.)Allergies (Please list any that apply: food, latex, makeup, plant or pollen allergies, etc.)Does this guest have special food needs?*(ie. food cut up, Thick-It for drinks, plain food, etc.) You can review the menu here.No Special Food NeedsCut Food Into Small PiecesPuree FoodOtherPlease explain any special food needs.*Does this individual have any violent tendencies that we should know about?*NoYesPlease explain any violent tendencies.*Parent/Caretaker InformationParent/Caregiver Name* First Last Parent/Caregiver Phone*Parent/Caregiver will be:**The Respite Room is a private area where parents/caretakers can spend the evening enjoying food, entertainment and rest while remaining onsite during the event.Dropping Guest OffEnjoying Respite RoomIf enjoying Caregiver Room, how many?Care Provider Agency Information - If ApplicableCare Provider Agency(If attending as a part of a group, please include agency or company name)Care Provider Agency PhoneAgency Chaperone (if applicable)(Note: Chaperone is not required to stay with guest(s) unless required by Care Provider Agency) First Last Additional Notes or ConcernsMedia & Liability ReleaseYou must agree to the following terms and conditions before submitting your registration. Registrations submitted without agreeing to these terms will not be processed.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 CHURCH, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a nonprofit corporation headquartered in Florida and CHURCH (“CHURCH”), a STATE nonprofit corporation, 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 CHURCH, 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 CHURCH, and to any benefits inuring to TTF and CHURCH as a result of its use of any of the foregoing recordings. Among other things, TTF and CHURCH 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 CHURCH, for the advancement of TTF and CHURCH’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and CHURCH 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 CHURCH, 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. I agree to the above Rights Release on behalf of myself and the Participant in my charge.