Clone of Register for Steubenville Youth Conference '25

Steubenville Participant Information
Participant's Name*

First NameLast Name
Participant's Birthday*

MonthDayYear
T- Shirt Size*
Grade Entering in Fall 2026
HS Graduation Year

Parent/Guardian Contact Information

Primary parent should be a legal parents or Guardian and will receive all communication, unless otherwise stipulated. Secondary Contact will be used only if the Primary Contact cannot be reached.
Primary Contact's Name*

First NameLast Name
Primary Contact's Cell Phone Number*

Area CodePhone Number
Primary Contact's E-mail*
Secondary Contact's Name*

First NameLast Name
Secondary Contact's Cell Phone Number*

Area CodePhone Number
Secondary Contact's E-mail*
example@example.com
Emergency Contact Information

Emergency contact should not be the same as the Primary or Secondary Contact
Emergency Contact Name*

First NameLast Name
Emergency Contact's Cell Phone Number*

Area CodePhone Number
Emergency Contact's E-mail*
example@example.com

Diocesan Permissions

Emergency contact should not be the same as the Primary Contact
I, {parentguardianName}, hereby give "My Child," {participantsName}, permission to travel (including in the airports, on the planes, and shuttles to and from the University) and participate in the Steubenville Main Campus 2 Conference trip to Steubenville, Ohio, from July 10, 2026, until July 13th, 2025.

I certify that My Child is physically fit and capable of taking part in the Activity.

I give permission for my Child to receive any emergency medical treatment deemed necessary until the Emergency Contact(s) can be notified, and I agree I will assume full responsibility for the payment of such treatment.
I agree to all of the statements above

Payment
In order to secure a spot for the participant, at least a $50 deposit must be received. You can choose to pay the deposit now and the rest later or you can make a full payment as well.

Full Payment: $250

Deadline for Full Payment: May 23rd

Deposits are non-refundable and must be made to secure a spot.

Please email brichards@olmmparish.org if you have any concerns about the deposit or the full cost of the conference.

If you cancel after May 23rd, then the full cost will be non-refundable.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Steubenville Conference Fee

Steubenville Deposit$50.00

Steubenville Full Payment$275.00

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

Parish Permissions
In the box below, I have listed any medical condition, physical disability, and medical, food, insect, and other allergies that may be relevant to rendering medical care. Any medication taken during the trip to and from the conference must be provided in its original container.
Allergies & Dietary Needs
I give permission for my Child to be photographed and/or recorded (photo, video, or audio) during participation in the Activity. I understand that these images or recordings may be used by the parish for promotional, educational, or informational purposes, including but not limited to parish publications, websites, social media, presentations, and other communications.

I acknowledge and consent to the parish/group phone policy, which requires participants to turn in their personal mobile phones to Blake Richards, group leader, each morning prior to the first scheduled session and to receive them back each evening after small group. I understand that phones will be securely stored by parish/group leaders during the day and that this policy is intended to support attentiveness, participation, and community during the conference. Please speak to Blake Richards for alternative options.

I understand that staff will use their best efforts to supervise the Activity; however, I agree and acknowledge that the Roman Catholic Bishop of Manchester, a Corporation Sole d/b/a as the Sponsor Organization, and its respective directors, officers, trustees, employees, and volunteers shall not be responsible for bodily injury or loss of or damage to personal property that may result from the Steubenville Conference trip.

By signing below, I agree to all of the terms above.
Signature*

Clear
By clicking "Submit," I, as the parent/guardian, agree to pay the Full Payment of $275 by May 23rd (unless otherwise arranged with OLMM or Saint Theresa's) and agree to the cancellation policies stated above.
Should be Empty:

Steubenville Participant Information

Parent/Guardian Contact Information

Emergency Contact Information

Diocesan Permissions

Payment

Parish Permissions