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Steubenville Private
Steubenville Private
Noor Atisha
2022-05-08T15:15:57-04:00
All fields are required to submit application.
Retreatant Information:
Student's Full Name
*
Gender
*
Female
Male
Age on July 18, 2022
*
Grade level in Fall 2022
*
9th Grade
10th Grade
11th Grade
12th Grade
2022 Graduate
T-Shirt Size (Adult sizes only)
*
Small
Medium
Large
X-Large
Student and Parent Contact Information:
Student Cell Phone Number
*
Student Email Address
*
Parent/Guardian Email Address
*
Parent/Guardian Cell Phone Number
*
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Emergency Contact Name
*
Emergency Contact Phone Number
*
Emergency Contact Relationship
Please list any allergies, medications, or any other information that we need to know.
Do you have a coupon code?
*
No
Yes
Scholarship Coupon Code
*
There will be only an option for a one time payment
*
One-Time Payment
Includes conference admission, transportation, lodging, all meals.
One-Time Payment
*
Price:
Sibling Coupon Code
Discount
$0.00
Total
Credit Card
*
American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
Month
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
Security Code
Cardholder Name
Terms & Conditions
*
There is certain behavior and certain expectations that are encouraged on this journey. I understand that this journey is to focus on my personal relationship with God. I agree that if I am found in possession of or participating in any way with drugs or alcohol, parent/guardian will be called and I will not be allowed to participate in any activities socially, only spiritually. I further understand that this is a coordinated by our Catholic Chaldean Church and I am expected to participate in all planned meetings and activities and abide by all rules. By checking the box above, I am agreeing with all terms mentioned and all my information that I completed above is true.
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