Refuge 2023 - Steubenville Youth Conference

Registration

Who : Incoming Freshman - Graduating Seniors

Where : Alexandria, LA

When : June 23-25, 2023

Cost : $350.00

Cost may be paid in full or in three installments:

- Deposit: $100.00 (Due at registration, reserves spot)

- Second Payment: $125.00 (Due May 31)

- Third Payment: $125.00 (Due June 16)

For more info on Steubenville South...

We do not want any student to miss out on this opportunity for financial reasons. To inquire about scholarships or financial aid, please contact Jacob Zamarron. (dre@stphilipcc.com)

Student Information

Student Name

First Name*

Last Name*

Date of Birth

Required* //

Grade Level 2023/2024

Required*

Where will student attend school for 2023/2024 school year?

Required*

Parent Information

Parent Name

First Name*

Last Name*

Parent Phone #

Required* --

Parent E-Mail

Required*

Street Address

Street 1*

Street 2

City*

State*

Zip*

Emergency Contact Information

EC Name

First Name*

Last Name*

EC Phone

Required* --

Medications/Disabilities

Please list any drug or food allergies that your teen may have, as well as, medications that your teen may need to take.	Mark "N/A" if none.*

Liability Waver

I agree on behalf of myself, my heirs, successors, personal representatives and assign to protect, indemnify, save, and hold harmless the Diocese of Corpus Christi, St. Philip the Apostle Catholic Church and their officers, directors, agent's employees, or representatives associated with the Steubenville from all damages, claims, suits, expenses and payment on account of or resulting from conditions stated on or resulting from any such injury, death, or damage to property, including resulting from the negligence of the Diocese of Corpus Christi, and parish, and or their officers, directors, and employees arising from or in connection with my attending Steubenville from June 23-25, 2023.

List (Single Choice)
Required*

I agree

Photography Consent

I give permission for my child (listed above) to be photographed at the Steubenville South Conference from June 23-25, 2023. It is okay to use photos of my student alone and/or in a group setting for social media, presentations, future marketing, etc.

List (Multiple Choice)
Required*

	I agree
	I do not agree

Payment

Shopping BasketRequired* The total cost of $350, which includes a deposit of $100 and two payments of $125.

		Selection	Extended

	Steubenville Deposit \| $100.00
	1st Payment (Due May 31) \| $125.00
	2nd Payment (Due June 16) \| $125.00
	OR Pay in Full \| $350.00 Full Cost of Conference

Order Summary

Subtotal
Discount
Sales Tax
Shipping & Handling
Total

Payment Type Credit Card
ACH / eCheck

Credit Card

Name on Card
First Name*	Last Name*

Card Number* - - -

Accepted Types

Security Code (CVV2)* | What's this?

Expiration Date*

Billing Address

Street 1*

Street 2

City*

State*

Zip*

Provide the billing address

Phone Required* -- Provide a contact phone number for the billing contact.

ACH / eCheck

Name on Account
First Name*	Last Name*

Routing Number*

Account Number*

What type of account is this?*
Checking
Savings

Billing Address

Street 1*

Street 2

City*

State*

Zip*

Provide the billing address

Phone Required* -- Provide a contact phone number for the billing contact.

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Refuge 2023 - Steubenville Youth Conference

Registration

Steubenville Deposit | $100.00

1st Payment (Due May 31) | $125.00

2nd Payment (Due June 16) | $125.00

OR Pay in Full | $350.00