Steubenville Private

All fields are required to submit application.

Retreatant Information:

Student's Full Name*

Gender*

Age on July 18, 2022*

Grade level in Fall 2022*

T-Shirt Size (Adult sizes only)*

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?*

Yes

Scholarship Coupon Code*

There will be only an option for a 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

Card Number

Expiration Date

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.