Steubenville Atlanta Registration Life Teen Steubenville Atlanta Registration Student Name* First Last Gender* Female Male Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student Email* Student Cell Student Grade level*8th9th10th11th12thName of current School* T-shirt Size*Adult XSAdult SmallAdult MediumAdult LargeAdult XLOtherParent Name* First Last Parent Phone*Parent Email* Emergency Contact Name* First Last Emergency Contact Phone*Media ConsentWhile on retreat, there will be photos taken and your student may be in them. Do we have your permission to use the photos from the retreat to post on our Social Media accounts (Facebook, Instagram, or Twitter) and to potentially have them in our parish bulletin or website? Names are not displayed with photos that are used in our parish media. I agree to the media policy.Steubenville Registration Quantity* Price: $325.00 Quantity Help offset the processing fee (optional) QuantityThis will add 2.5% to your total to offset the credit card processing fee we are charged. Price: $0.00 Quantity Total $0.00 Credit Card*Card Details Cardholder Name