Steubenville Student Registration

Emergency Medical/Permission Form

Steubenville of the Rockies
I/We, {parentguardian}, as the parents/legal guardian of {participantName}, a minor residing at the address above, hereby grant the Diocese of Grand Island, their staff, parish staff, and parish adult volunteer leaders permission to transport this minor to an emergency medical or health care facility for immediate treatment and/or consultation, if deemed necessary. I/We understand that I/we will be notified of any emergency situation. I/We give authorization to the attending physician, dentist, or medical personnel for any required immediate treatment in the event that I/we cannot be reached at the time of the emergency. I/We agree to be financially responsible for any and all medical expenses and/or treatment costs and all related services provided to the above-mentioned minor, and I/We release the Diocese of Grand Island, their staff, parish staff, and parish adult volunteer leaders from any liability.

I/We understand that this event is sponsored by the Diocese of Grand Island. I hereby grant permission for MY/OUR son/daughter to participate in the Steubenville of the Rockies Conference including all transportation to and from the event. I/We accept full responsibility for any legal or financial consequences which may result from any personal actions (ie. damage to property or other participants/staff) taken by MY/OUR son/daughter, and I/WE agree to hold the Diocese of Grand Island, their staff, parish staff, and parish adult volunteer leaders harmless with respect to any actions or claims that may be made in connection with personal actions taken by MY/OUR son/daughter. I/WE also grant permission the Diocese of Grand Island, their staff, parish staff, and parish adult volunteer leaders to use photo and video of MY/OUR son/daughter for publicity/marketing purposes.

I/We authorize the release of information to my/our insurance company and family physician:
Insurance Company Name*
Policy Number*
Phone Number*

Area CodePhone Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Name*
Physician's Phone Number*

Area CodePhone Number
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This minor has the following ALLERGIES:*
(including food allergies)
This minor has the following MEDICAL CONDITIONS:*
(including mental health or pregnancy)
This minor is currently taking the following MEDICATIONS:*
I prefer that she/he be responsible for these Medicatiions her/himself.I prefer that the staff hold these medications and dispense according to the directions.
I DO give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment.I DO NOT give permission for this minor to be given over-the-counter treatments (such as Tylenol, Tums, Sudafed, etc) if she/he experiences discomfort and requests treatment.
Parent/Guardian Signature*

Clear
Parent(s) address if different from student

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work or Alternative Number

Area CodePhone Number

Code of Conduct
To accomplish the purpose of the Steubenville of the Rockies, everyone must agree to a “Code of Conduct.” These guidelines are necessary to make the event enjoyable for all and to avoid problems. Participants have a responsibility to themselves and others to follow these guidelines:
- Be Respectful and Safe. At Steubenville of the Rockies we expect to create an environment of safety and trust. The use of our bodies, language, and humor must always honor the dignity of every person. If you jeopardize the physical or emotional safety of yourself or the group, you choose to have a parent or guardian pick you up and take you home immediately.
- Be Responsible and Honest. Participants are expected to be present at all activities on time and participate fully. Established guidelines will be observed at all times. We need to take care of the building and grounds. Any damage is to be reported immediately and involved persons are financially accountable. Emergencies that involve the health and well-being of people and/or property must be reported to adult staff immediately.
- The use of illegal drugs, including alcohol, or other illegal/harmful substances is not permitted. If you use these materials, you choose to have a parent or guardian pick you up and take you home immediately. Proper authorities will be notified. Do not bring clothing that advertises/promotes alcohol, tobacco or drug use or anything displaying messages that are offensive or contain sexual innuendo. These are contrary to the values of a Catholic youth rally and are not acceptable at this event.
- Observe appropriate boundaries. All participants must stay in designated areas. Males and females are lodged in separate rooms. Participants do not enter each other’s rooms unless supervised by an adult. One of our goals is to relate with everyone present; therefore, during the weekend, exclusive relationships are discouraged. If you engage in activities contrary to these guidelines or any activities that jeopardize your safety or the safety of the group, you choose to be removed from the event. Your parent or guardian will be called to pick you up and take you home immediately.
Dress Code
In order to promote a safe, healthy and positive community experience the following dress code must be followed by all male and female participants and adult leaders. Clothing should be modest and appropriate to a youth retreat/conference setting. Clothing should not present messages contrary to the values of a Catholic youth program.
- All attire should be sized to fit without exposing undergarments, buttocks, stomachs or cleavage.
- Shirts must be long enough to naturally touch the top of the lower garment, with arms raised.  Shirts must cover the shoulders. No Spaghetti straps, tank tops, and halter tops or transparent/mesh clothing or shirts with revealing necklines or armholes.
- Shorts and skirts must be fingertip length when arms are resting at sides.
- No yoga pants or form-fitting pants/shorts.
- No clothing or accessories that promote drugs, alcohol or tobacco either by brand or message.
- No clothing or accessories with sexually suggestive language or messages or clothing or accessories that promote violence, criminal activity, intimidation or intolerance of others (based on religion, ethnicity, gender or lifestyle).
- Modest swimsuit appropriate for a Catholic retreat setting, No Speedos or bikinis.
Parent & Participant Signature:

I/We understand and accept the guidelines and policies stated in this Code of Conduct. I will accept the consequences should my son/daughter choose to violate the code. I agree to come to the retreat and pick up my son/daughter, should he/she choose to behave in a manner that the director and staff judge to be a serious violation of this code and is contrary to the mission of the Steubenville Conferences.
Parent/Guardian Signature*

Clear
Participant Signature*

Clear
Date

MonthDayYear

Communications
Please note that all communications relating to diocesan youth events are through email. You will receive a confirmation email upon registration, if you do not find it in your inbox immediately, please check your junk file. If the confirmation email is not received, please contact us.

Additional communications relating to this event will be sent approximately 3 weeks prior to departure. Please check your email and junk mail regularly for these communications.

Payment (Select one payment option. The processing fee is optional.)*

$100 Non-Refundable Steubenville Deposit $100.00

Full payment due April 15, 2026

Steubenville Full Payment (includes a $100 non-refundable deposit)$399.00

Early Bird rate through 2/8/2026

Processing Fees$7.50

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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Student Registration

Emergency Medical/Permission Form