2024 Steubenville Registration
Christ the King for All group
For information on the Steubenville Youth Conference, please visit: www.steubystl.com
Participants Details
Legal Name
*
First Name
Last Name
Nickname
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Cell Phone
Youth E-mail
example@example.com
Grade finishing May 2024
*
Please Select
8th
9th
10th
11th
12th
Graduation Year
*
School
*
Parish
*
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
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Parent Details for Correspondance
Parent/Guardian 1 Name
*
First Name
Last Name
Parent 1 Mobile Phone
*
Please enter a valid phone number.
Parent 1 Email
*
example@example.com
Parent/Guardian 2 Name
First Name
Last Name
Parent 2 Mobile Phone
Please enter a valid phone number.
Parent 2 Email
example@example.com
Home Phone
Please enter a valid phone number.
Secondary Emergency Contact
Name
*
First Name
Last Name
Primary Phone
*
Please enter a valid phone number.
Secondary Phone
Please enter a valid phone number.
Relationship to Participant
*
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Medical Details
Health Insurance
*
Insurance Policy Number
*
Doctor's Name
*
First Name
Last Name
Doctor's Phone Number
*
Please enter a valid phone number.
Does the participant require any medications?
*
Yes
No
If Yes, please specify, to include purpose, dosage, frequency.
Who will administer the medication?
Please Select
Participant
Leader
Family Member
Does the participant have any dietary restrictions or food allergies?
*
Yes
No
If Yes, please specify.
Does the participant have any other allergies? (medications, plants, insects, etc.)
*
Yes
No
If Yes, please specify.
Do you OBJECT to non-prescription medications (such as ibuprofen, acetaminophen, throat lozenges, cough syrup, etc.) being given, if deemed necessary?
*
Yes
No
Has the participant had any recent illnesses or exposures (e.g. mumps, measles, chickenpox, COVID-19, etc.)?
*
Yes
No
If Yes, please specify.
Year of last tetanus shot
*
Is there any other information about the participant that you should disclose in order to protect their, or others, health, safety, comfort, or wellbeing? (E.g. physical limitations, sleepwalking, fainting, homesickness, etc.)
*
Yes
No
If Yes, please specify.
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Steubenville Details
T-shirt size
*
Small
Medium
Large
Extra Large
2XL
3XL
How many years have you attended Steubenville?
*
Who invited you to Steubenville?
*
Please list up to 3 individuals you would like to room with. There are no guarantees.
In previous years, accommodations have been 2-4 people in a room, with the potential need for an air mattress or additional bedding to accommodate. We will inform you of the room accommodations once we have been notified by the Steubenville Conference. Participants from different groups will not be roomed together in the same room. If roomed in suite-style housing, multiple groups may be housed in the same unit, but will still be separated by sleeping spaces. We will do our best to accommodate room request or pair you based on parish and/or chaperones.
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Registration confirmation
I understand that my 2024 Steubenville registration is NOT confirmed until my non-refundable $50 deposit has been received, and that I will be expected to submit the full payment by the due date. I understand that I can pay up to the total cost of $350 at any time. Any additional donations will be applied to transportation costs. (Scholarships are available and information will be sent at a later date).
*
Yes
I understand that I will be required to sign an Archdiocese of Omaha Parent/Guardian Consent Form and Liability waiver and my child will be required to sign an Archdiocese of Omaha Youth Code of Conduct form in order to complete the registration. These forms will be provided at a later date and will need to be given to a Leader at or before the first formation session. (A second digital form for the Archdiocese of St. Louis will also be emailed at a later date once we receive it).
*
Yes
I understand that my child will be required to attend three formation sessions leading up to the Steubenville Conference. Excused absence must be received from a Leader over 48 hours prior to a formation session.
*
Yes
I hereby warrant that to the best of my knowledge, the above participant is in good health, and I assume all responsibility for their health.
*
Yes
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