Steubenville/Rochester Youth Conference

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July 15 -17, 2022

Email *

Participant Name *

Grade *

Student Mailing Address *

Student Email *

Student Cell Phone *

Home Phone *

Gender *

Male

Female

Birthdate *

YYYY

T-Shirt Size (Adult) *

XXL

How many Rise Up conferences have tou attended before? *

Special Diet or Allergies *

Chronic Medical Problems *

Current medications & reason for taking: *

Mother's name and address (if different than student's) *

Mother's cell phone *

Mother's email address *

Father's name and address (if different than student's) *

Father's cell phone *

Father's email address *

Emergency Contact *

Relationship to student *

Emergency Contact Home Phone *

Emergency Contact Cell Phone *

I am the parent or guardian of the student registered above and I do hereby give permission to have my son/daughter attend Steubenville/Rochester Youth Conference in Rochester, MInnesota on July 15-17, 2022. I understand that in order for my child to attend this conference, he/she must comply with all rules related to the Conference. *

Yes

Name of person filling out this form and giving permission. *

I will turn in our $50 deposit to St. Mary's Parish office within 1 week of submitting this form. Checks can be made payable to St. Mary's. *

Yes!

Other:

I would like to volunteer (your name and email address)

A copy of your responses will be emailed to the address you provided.

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