Steubenville Atlanta Registration

Student Name*
First Last
Gender*
- Female
- Male
Home Address*
Street Address City State ZIP Code
Student Email*
Student Cell
Student Grade level*
Name of current School*
T-shirt Size*
Parent Name*
First Last
Parent Phone*
Parent Email*
Emergency Contact Name*
First Last
Emergency Contact Phone*
Media Consent
While 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
Help offset the processing fee (optional) Quantity
This will add 2.5% to your total to offset the credit card processing fee we are charged.
Price: $0.00
Total
$0.00
Credit Card*
Card Details
Cardholder Name