Steubenville Registration

Number of Student(s) being registered for Steubenville REQUIRED Please fill out this field.
Student's Information 1
- Student's Complete First Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Female Male Please fill out this field.
- Parish REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- What Grade is Student entering into in the Fall? REQUIRED 9th 10th 11th 12th Freshmen in College Please fill out this field.
- Student's Cell Phone Number (used if student gets separated from group) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Student's Email (Please DO NOT put Parent's email in this space)(this is used to send them information in the days leading to the conference) REQUIRED Please fill out this field. Please enter an email address.
- List Names of potential roommates: (There is no guarantee that your student will paired with the person(s) selected by the parent but that selection will be taken into consideration)
Student's Information 2
- Student's Complete First Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Female Male Please fill out this field.
- Parish REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- What Grade is Student entering into in the Fall? REQUIRED 9th 10th 11th 12th Freshmen in College Please fill out this field.
- Student's Cell Phone Number (used if student gets separated from group) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Student's Email (Please DO NOT put Parent's email in this space)(this is used to send them information in the days leading to the conference) REQUIRED Please fill out this field. Please enter an email address.
- List Names of potential roommates: (There is no guarantee that your student will paired with the person(s) selected by the parent but that selection will be taken into consideration)
Student's Information 3
- Student's Complete First Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Female Male Please fill out this field.
- Parish REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- What Grade is Student entering into in the Fall? REQUIRED 9th 10th 11th 12th Freshmen in College Please fill out this field.
- Student's Cell Phone Number (used if student gets separated from group) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Student's Email (Please DO NOT put Parent's email in this space)(this is used to send them information in the days leading to the conference) REQUIRED Please fill out this field. Please enter an email address.
- List Names of potential roommates: (There is no guarantee that your student will paired with the person(s) selected by the parent but that selection will be taken into consideration)
Student's Information 4
- Student's Complete First Name (First, Middle, Last) REQUIRED Please fill out this field. Please enter valid data.
- Gender REQUIRED Female Male Please fill out this field.
- Parish REQUIRED Please fill out this field. Please enter valid data.
- Date of Birth REQUIRED Please fill out this field. Please enter valid data.
- What Grade is Student entering into in the Fall? REQUIRED 9th 10th 11th 12th Freshmen in College Please fill out this field.
- Student's Cell Phone Number (used if student gets separated from group) REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
- Student's Email (Please DO NOT put Parent's email in this space)(this is used to send them information in the days leading to the conference) REQUIRED Please fill out this field. Please enter an email address.
- List Names of potential roommates: (There is no guarantee that your student will paired with the person(s) selected by the parent but that selection will be taken into consideration)

Who should receive emails about Steubenville information? Mom and Dad Only Mom Only Dad

Mother's Email Please enter an email address.

Father's Email Please enter an email address.

By checking box below, I hereby GRANT permission for my student(s) listed above to attend the Steubenville Youth Conference held in Springfield, Missouri with Christ the King Catholic Church's staff and volunteers. REQUIRED Acknowledgement of statement above. Please fill out this field.

Custodial Parent/Guardian Signature: REQUIRED Please fill out this field. Please enter valid data.

Date REQUIRED Please fill out this field. Please enter a date.