To request a scholarship, please contact Keith Call at kcall@sttimothymesa.org

Today I am registering*

Teen Information


Name*
Gender*
Date of Birth*
Grade for the 2019-20 academic year*
T-Shirt Size (adult sizes only)*
* For the well-being of all teens, all prescription medication will be held by designated St. Timothy's Core members during the conference. Any teen taking prescription medication must be able to request their medication from their Core member as needed. Any teen who is unable to request and dispense his or her own medication must make arrangements with event leaders to provide an adult aid 21+ years old to attend with them.
My son/daughter has my permission to receive over the counter medication and basic first aid treatment if necessary.*

Teen Information

Name*
Gender*
Date of Birth*
Grade for the 2019-20 academic year*
T-Shirt Size (adult sizes only)*
* For the well-being of all teens, all prescription medication will be held by designated St. Timothy's Core members during the conference. Any teen taking prescription medication must be able to request their medication from their Core member as needed. Any teen who is unable to request and dispense his or her own medication must make arrangements with event leaders to provide an adult aid 21+ years old to attend with them.
My son/daughter has my permission to receive over the counter medication and basic first aid treatment if necessary. - Copy*

Parent/Legal Guardian Information


Parent/Legal Guardian Name*
Parent/Legal Guardian Name

Emergency Contact Information


Emergency Contact Name (other than parent(s) listed above)*

PARENT/LEGAL GUARDIAN WAIVER

I request that the St. Timothy Catholic Church program allow my child(ren) to attend Life Teen’s Steubenville West from July 19-21, 2019 at University of Arizona in Tucson, AZ. In consideration for my child's participation, on behalf of myself, my child, and our heirs, assigns, executors and personal representatives, I hereby release, absolve, indemnify and agree to hold harmless St. Timothy Roman Catholic Parish Mesa, the Roman Catholic Church of the Diocese of Phoenix, and any and all of their officers, directors, agents, employees, representatives, volunteers, or sponsors from any and all liability for any and all injury that may arise out of participation in this activity. I understand that St. Timothy Catholic Church and the Diocese of Phoenix will not be liable if my child fails to cooperate with regulations and that any infraction of the rules may result in immediate dismissal from the retreat at my expense. I also authorize the supervisors of Steubenville West & St. Timothy Life Teen programs or his/her designee to provide first aid or similar care in non-emergency situations, and to seek emergency medical assistance when they deem it necessary, for which I will be financially responsible. Further, I give permission to have photos taken of my child for the purpose of parish use. Should it be necessary for my child or youth to return home due to medical reasons, disciplinary action or otherwise (as determined by youth minister), I understand that I am responsible for picking up my youth or arranging for transportation in a timely manner, and assuming all transportation costs and responsibility. I understand that as a preventive measure and in order to maintain a safe environment, random searches of youths’ personal possessions may be made. I agree that my youth’s personal possessions may be searched when or if a youth minister has reasonable suspicion that a youth may possess an item in violation of event rules.

"I represent and certify that I, as parent/guardian of the child(ren) named above, have read the entirety of this agreement and fully understand the contents, consequences, and implications of signing this agreement, and that I agree to be bound by this agreement."*
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Today's Date*

Please contact Meagan Martinez at (480) 775-5234.

TEEN/PARTICIPANT WAIVER

In applying to participate in the Steubenville West Conference, I agree to cooperate with Meagan Martinez, the core team and the staff at Steubenville West. I intend to exercise sound judgment and to follow all the rules as stated at the outset of the conference, knowing that failure to do so will result in my dismissal at my parent’s expense. Further, I agree that I will not bring alcohol, illegal drugs, cell phones, laptops, iPads, mp3 players or weapons of any kind.

"I represent and certify that I have read the entirety of this agreement and fully understand the contents, consequences, and implications of signing this agreement, and that I agree to be bound by this agreement."*
Use your mouse or finger to draw your signature above
Today's Date*
Use your mouse or finger to draw your signature above
Today's Date*

Please contact Meagan Martinez, 480-775-5234.

You have selected the payment plan option. 

Please complete the following credit card information below.

Credit Card Holder's Name*
I would like my payments withdrawn on...*
I would like my payment plan to be...*

Registration for the Steubenville is not complete until payment is made. 

You will be directed to PayPal after clicking the "submit form" button. Once the payment is submitted you will receive a confirmation email confirming we received your registration. 

Registration for the Steubenville is not complete until deposit is made. 

You will be directed to PayPal after clicking the "submit form" button to pay the deposit. Once the deposit is paid you will receive a confirmation email stating that registration is complete.

I understand my registration is not complete until payment or deposit is made*
I authorize St. Timothy's Church to charge the credit card provided herein for the purpose of setting up a payment plan. I agree to pay for this purchase in accordance with the issuing bank cardholder agreement.*
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