EmailMeForm
Steubenville Atlanta Conference 2024
Catholic Archdiocese of Atlanta
All Saints Catholic Church
JULY 26-28, 2024
Total Cost: $250
Nonrefundable Deposit: $75
*** Student's INFORMATION ***
Name of Student
*
First
Middle
Last
Nickname
Grade (2024-2025 School Year)
*
8th - Grad 2029
9th - Grad 2028
10th - Grad 2027
11th - Grad 2026
12th - Grad 2025
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
*
Blessed Trinity Catholic HS
Chamblee Charter
Dunwoody High School
Greater Atlanta Christian School
King's Ridge Christian School
Marist
Mount Vernon School
Norcross High School
North Springs Charter High
Notre Dame Academy
Saint Francis
Shamble High School
St. Pius X
Wesleyan School
Regina Caeli Academy Homeschool Hybrid
Home School
Other
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: 15 Passenger Bus
*** 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
