Steubenville Registration Form
Steubenville Conference June 21-23
First Name of Youth : *
Your answer
Last Name of Youth : *
Your answer
Participant Gender: *
Date of Birth: *
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Grade Entering 2019-2020: *
School *
Your answer
T-shirt Size *
Will you be applying for the Steubenville LEAD program June 17-21? *
Participant Mailing Address: *
Your answer
City: *
Your answer
State: *
Your answer
Zip code: *
Your answer
Participant Mobile Phone #:
Your answer
Mother/Guardian First Name: *
Your answer
Mother/Guardian Last Name: *
Your answer
Mother/Guardian Phone: *
Your answer
Father/Guardian First Name: *
Your answer
Father/Guardian Last Name: *
Your answer
Father/Guardian Phone: *
Your answer
Additional Emergency Contact Name: *
Your answer
Additional Emergency Contact Phone Number: *
Your answer
Chronic Conditions, special medical conditions, and/or physical limitations: *
(e.g. Epilepsy; Diabetes; Paraplegic; etc.)
Your answer
Allergic Reactions: *
(e.g. Food; Medications; Plants; etc.)
Your answer
Dietary Restrictions: *
Your answer
Current Medication: *
The Participant is taking medication at present. The Participant 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:
Your answer
Medical Insurance:
Your answer
Policy Number:
Your answer
Insurance Member's Name:
Your answer
Insurance Phone #:
Your answer
Family Doctor Name:
Your answer
Family Doctor Phone #:
Your answer
Non-Prescription Medication *
Consent to Release of Photographs *
Do you hereby consent to the release of photographs and name of the Participant to be used by the Diocese of Columbus, and its parishes and schools, for future promotional programs of the Diocese, and its parishes and schools?
Permission, Release and Indemnification, and Code of Behavior *
I have read and agree to all the terms and conditions list in the Permission, Release and Indemnification, and Code of Behavior found here: https://columbuscatholic.org/documents/2019/1/Bosco%20Bash%20Permission%20Release%20and%20Idemnification%20and%20Code%20of%20Behavior.pdf
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