EmailMe Form - Steubenville Atlanta Conference 2024

* Student's INFORMATION *

Name of Student *

First Middle Last

Nickname

Grade (2024-2025 School Year) *

Birthday *

MM / DD / YYYY

Teen's age *

Age of teen when they will be at Conference

Gender *

Male

Female

Do you give permission for Youth Director to email your teen? *

Yes

No

Youth's Email

Name of School *

Other School Name

If your school name wasn't listed please type here.

Teen's Favorite Snacks *

What are some your teen's hobbies? *

Side Notes

Anything we should know about your teen that can help us journey with him/her in the faith.

* Parents/Guardian INFORMATION *

Primary Parent/Guardian's Name *

First MI Last

Primary Parent/Guardian's Email *

Primary Parent/Guardian's Phone Number *

### - ### - ####

* Travel Information *

Individual in Charge:
Jesse Butrum

Drop off time: 2:30 pm Fri. July. 26th, 2024 At All Saints

Pick Up Time: between 12:45 pm & 1:00 pm Sun. July. 28th, 2024 at All Saints.

Mode of Transportation to and from the event: Car Pooling

* MEDIA RELEASE FORM *
REF ID#: YP-MEDIA-04302013.14

Our parish, All Saints Catholic Church, uses images, interviews, and videos of our children for a variety of internal and external communications. Our forms of internal and external communications include but are not limited to: print, such as newspapers, bulletins, and newsletters; photographs and digital images; film and videos; web posts, web pages, and image carousels; social networking platforms including but not limited to Facebook, Twitter,
and Instagram.

We follow the Archdiocese of Atlanta’s Social Media Policy and Guidelines for the Use of Social Networking Sites with
Minors. Please see this resource for more information.

Please indicate below whether our parish and/or school has permission to circulate interviews, images, and/or videos of your child for all parish and/or school events for one year: *

*

NO, I do not want my child included in, nor my child’s image used, in any internal or external communications.

I hereby grant permission for the following parish, All Saints Catholic Church, to use images and interviews of my child and/or children, for internal or external communications for one year.

My child may be photographed and/or interviewed for The Georgia Bulletin, and other media outlets. I understand content may be reprinted in The Georgia Bulletin or other media for public dissemination, including but not limited to film; video; television; radio; newspapers such as The Atlanta Journal and Constitution; websites and online platforms; and social media networks including but not limited to Facebook, Twitter, and Instagram. I release and relieve the parish and/or school, and the Archdiocese of Atlanta, from any responsibility or liability for any claims arising from the publication or reproduction of any photographs or interview in any news or other media. I waive any and all right to inspect or approve the finished images, video, or printed matter that may be used in conjunction with any image or video, or to approve the eventual use for which it may be applied. I understand that photographs, videos, and/or interviews are being done with the knowledge and approval of the parish and/or school, and that a signed release form is required for every participating individual.

By parent or guardian initialing here, permission is granted for non-prescription medications to be given, if deemed appropriate by adult chaperone(s). *

Signature of Parent or Legal Guardian *

Clear

Date Time *

MM / DD / YYYY

* Teen's agreement *

I agree to abide by any / all policies and rules established for this event / activity. Should I not be able to maintain the guidelines and expectations of the adults and my peers, I understand that there will be consequences for my actions, including being removed from the activity and being sent home at my parent’s expense.

Basic rules / expectations include, but are not limited to, the following: Respect for all adult leaders, peers, and all property; NO illegal drugs, alcohol, underage smoking, firearms, explosives, or other illegal substances; Males and females are to remain in separate sleeping spaces at all times; No inappropriate physical / sexual activity; Appropriate attire is to be worn at all times. Other guidelines may be set forth accordingly by adult chaperones present for the event(s).

Teen Signature *

Clear

Date Time

MM / DD / YYYY

*** Student's INFORMATION ***

*** Parents/Guardian INFORMATION ***

*** Travel Information ***

*** MEDIA RELEASE FORM *** REF ID#: YP-MEDIA-04302013.14

*** Teen's agreement ***

* Student's INFORMATION *

* Parents/Guardian INFORMATION *

* Travel Information *

* MEDIA RELEASE FORM *
REF ID#: YP-MEDIA-04302013.14

* Teen's agreement *