Steubenville Registration 2018
GLOW is going to shine at the Steubenville Youth Conference in Rochester, MN this summer!
Mark your calendars for, July 13-15, 2018. This awe-inspiring, faith-awakening event is open to all current 8th-12th grade youth. With fan-favorite Steve Angrisano headlining this year, and other fantastic speakers like Sarah Swafford and Brian Greenfield in the mix, it’s sure to be a memorable weekend!

Steubenville Youth Conference Pricing Structure:
Regular Registration: If registering between December 17, 2017 – April 29, 2018
Cost: $325 ($100 deposit, plus three additional payments of $75)
Late Registration: If registering on or after April 30, 2018
Cost: $355 (Please pay in full.)

If payment assistance or a separate payment schedule/arrangement is needed, please ask!

All Star Speaker Line Up
Basic Personal Information
First Name *
Your answer
Last Name *
Your answer
Gender
Date of Birth *
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DD
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Graduation Year *
What parish do you attend?
Your answer
Is this your first time attending a Steubenville Youth Conference?
Who invited you to attend this year's conference?
Your answer
T-Shirt Size *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Home Phone Number *
Your answer
Youth Cell Number
Your answer
Youth Email Address
Your answer
Parent/Guardian Name *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Medical Matters
I hereby warrant that to the best of my knowledge, my child is in good health, and I assume all responsibility for the health of my child. *
Emergency Medical Treatment
In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical or surgical treatment. I wish to be advised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:
Emergency Contact Name *
Your answer
Emergency Contact Phone Number *
Your answer
Relationship to the Participant *
Your answer
Name of Family Doctor *
Your answer
Family Doctor Phone Number *
Your answer
Family Health Plan Carrier *
Your answer
Policy Number *
Your answer
Other Medical Treatment
Is your child currently taking prescription medication? *
My child is taking medication at present. *
My child will bring all such medications necessary, and such medications will be well-labeled. Names of medications and concise directions for taking such medications, including dosage and frequency of dosage, are as follows: (If in High school, my child will take responsibility for taking these as described). **May write "Not Applicable" if child is not currently taking medication. *
Your answer
Permission to administer medication if necessary? *
Specific Medical Information
The parish/school/Archdiocese will take reasonable care to see that the
following information will be held in confidence.
Allergic reactions (medications, foods, plants, insects, etc.): *
Your answer
Immunizations: Date of last tetanus/diphtheria immunization: (MM/DD/YYYY) *
Your answer
Does the child have a medically prescribed diet? *
Your answer
Is the child subject to chronic homesickness, emotional reactions to new situations, sleepwalking, fainting? *
Your answer
Has the child recently been exposed to contagious disease or conditions, such as mumps, measles, chickenpox, etc? If so, date and disease or condition: *
You should be aware of these special medical conditions of my child: *
Your answer
Payment Agreement
Below is the Payment Agreement for the Steubenville Conference 2018. A link to this agreement will be sent to you upon submission of this form, and is also available on the St.Gerald Website, on the Youth Ministry page.
Name and Relationship to the Participant *
Your answer
Additional Questions or Comments
How can we help you?
Your answer
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