Shining Star/Youth Information

Youth's First Name

Youth's Last Name

Date of Birth

Youth's Email (if applicable)

Is this youth currently a Shining Star?

Street Address

City

State

Zip Code

5-Digit Zip Code Calculation

Type of Seizures/Epilepsy:

Seizure Triggers (if applicable)

Primary Guardian Information

First Name

Last Name

Guardian's Phone

Guardian's Email

The confirmation email and event reminders will be sent to this email.

How did you hear about this event?

Please specify:

Will there be additional guests?

Additional Guests

First Name

Last Name

Guest's Email

OPTIONAL

Guest's relationship to Shining Star/Youth:

Please click on "Add another response" to add more guests to your reservation.

Number of guests

Total Guests

Payment

Your Shining Star will receive a free Unlimited Ride Wristband for Nickelodeon Universe. Additional Wristbands for guests are $18 (Wristbands purchase at Nickelodeon Universe are $44.99).

How many Wristbands will you need to purchase?

Total Cost ($):

Payment Method:

Credit CardBank Account (ACH)Will pay cash at eventFinancial support requested

Payment Information

Name on Account

Bank Name

Bank Routing Number

Bank Account Number

Billing Account Number

Account Type

CheckingSavings

Payment Information

Name on Card

Card Number

Code

Billing Information

First Name

Last Name

Street Address

City

State

Zip Code

Phone

Numbers only. No dash/symbols needed

Contact Information