Steubenville Mid-America

PARENT/GUARDIAN INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Email Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

PARTICIPANT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

High School Graduation Year is: REQUIRED Please fill out this field.

My T-shirt Size is REQUIRED Please fill out this field.

Physician's Name: REQUIRED Please fill out this field. Please enter valid data.

Physician's Phone Number: REQUIRED Please fill out this field. Please enter valid data.

Insurance Company: REQUIRED Please fill out this field. Please enter valid data.

Insurance ID Number: REQUIRED Please fill out this field. Please enter valid data.

Any allergies or medical needs: REQUIRED Please fill out this field.

Is your child responsible for taking his/her own medication? REQUIRED Yes No Please fill out this field.

EMERGENCY CONTACT INFORMATION (NOT PARENT):

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

I hereby authorize my son/daughter to attend and participate in the Steubenville Conference July 10-12, 2020. I understand that my son/daughter will be offered the opportunity to participate in various activities. It is understood that all possible caution will be taken by those persons in charge to keep everyone safe and to prevent injuries, but the chaperones, the young adult leaders, teens, the sleep house parishioners, and Sacred Heart Church Valley Park will not be held responsible in the case of an accident or injury. I understand that if my youth behaves in a manner that is deemed inappropriate, is continually disruptive or is found with illegal drugs or alcohol, I will be called immediately to pick up my youth from the activity sight.

I hereby authorize any adult chaperone to consent to any medical treatment of the above named youth, which, in the judgement of a recognized medical facility, under the general or special supervision of a licensed physician, may be deemed necessary.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms and Conditions. REQUIRED I agree Please fill out this field.

Electronic Signature of Parent or Legal Guardian confirming the content of information on this form. REQUIRED Please fill out this field. Please enter valid data.

MEDIA RELEASE

I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, parish bulletin, school newsletter, student newspaper, admission videos, parish/school website and social media.

Please Check REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in communications that include, but are not limited to, archstl.org, St. Louis Review, Catholic St. Louis magazine, archdiocesan social media, The e-Vangelizer (newsletter published by the Catholic Education Office) and any publication(s) by agencies administered by the Archdiocese of St. Louis.

Please Check REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in websites, videos, and publications created by independent foundations and corporations that support Catholic education but are not legally connected to the Archdiocese of St. Louis, including, but not limited to, Today and Tomorrow Educational Foundation, Roman Catholic Foundation of Eastern Missouri, Access Academies, English Tutoring Project, and United Way.

Please Check REQUIRED Yes No Please fill out this field.

I grant permission to use my or my child’s image, name, recording, or academic work in secular media communications including, but not limited to, print, radio, TV and internet (Examples: St. Louis Post-Dispatch, KMOX radio, and KSDK-TV).

Please Check REQUIRED Yes No Please fill out this field.

When you click the "Proceed to Payment" button, you will be taken to the payment page to make your payment either by check or credit card. All payments are NON-REFUNDABLE. Remember - REGISTRATIONS ARE NOT COMPLETE until the required the retreat deposit is paid.

I Agree Please select this field.

Steubenville Deposit100.0