Steubenville Private "*" indicates required fields All fields are required to submit application. Retreatant Information:Student's Full Name*Gender*FemaleMaleAge on July 18, 2025*Grade level in Fall 2025*9th Grade10th Grade11th Grade12th Grade2022 GraduateT-Shirt Size (Adult sizes only)*SmallMediumLargeX-LargeStudent 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 RelationshipPlease list any allergies, medications, or any other information that we need to know.Do you have a coupon code?* No Yes Scholarship Coupon Code*There will be only an option for a one time payment*One-Time PaymentIncludes conference admission, transportation, lodging, all meals.One-Time Payment* Price: Sibling Coupon CodeDiscount $0.00 Total Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 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. Δ
