Starry Night Polk County

Guest Registration

Basic Information

Enter Parent or Guardian phone if necessary.
Enter Parent or Guardian email if necessary.
Are you in a private residence or a group home?
If in a group home, please specify its name here.

Guest Caregiver Contact Info

Past Buddy Request

If you have had a buddy for the past couple of years and would like for us to see if they are available again, please let us know here!

Guest Information

To make sure that we can make the appropriate volunteer services available for their special night we need to make sure we have enough information about the guest so that we can come prepared!To be clear; no guests will be turned away due to any particular disability and this information is only used to help us make sure we have the right volunteers that we need to accommodate the guest when they arrive for their special night!
Please provide any additional information or concerns that may be required for us to better prepare for our guests. (Health Concerns such as allergies can also be included here!)
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Leave blank if none.
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Guest Social Media Release Form

By signing below, and for the good and valuable consideration of participating in an event hosted by Victory Baptist Church, I hereby give my full consent to Starry Night Polk, a local organization located at Victory Baptist Church, a Georgia 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 Starry Night Polk and Victory Baptist Church ("Victory"), without roayalty 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 Starry Night Polk and Victory, and to any benefits inuring to Starry Night Polk and Victory as a result of its use of any of the foregoing recordings. Among other things, Starry Night Polk and Victory 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 forgoing privately or publicly, and use or license it or any of the foregoing for use by others, and for the sole benefit at the sole discretion of Starry Night Polk and Victory, for the advancement of Starry Night Polk and Victory's exempt charitable purposes. All permissions granted herein extend to any successor or assign of Starry Night Polk and Victory and bind me and my heirs, successors, and assigns, I, hereby release and discharge and agree to hold harmless Starry Night Polk and Victory, its directorys, 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 or have a guardian capable of the right to agree on my behalf.
For any on site emergencies please go to the Check In/Registration desk for assistance. They will have access to contacts and other resources.
Guest Pickup is at 9:00PM. Please have pickup arranged to arrive at this time!
By typing in the below fields, I am accepting this as my electronic signature of this form.