Registration Form / Waiver

Registration Form / Waiver

The Reality Tour® is a national project of CANDLE, Inc. a non-profit organization (www.RealityTour.org)

Tour begins at: 6PM at Parlier Junior High School 1200 E. Parlier Ave Parlier, CA 93748November 15, 2014 11:00AM-2:30PM120 W. Cunningham4:00 St

___ Oct 9 ___ Nov 13 ___ Dec 11 __

IMPORTANT REGISTRATION INFORMATION:

Your reservation will be confirmed!

EVERY ATTENDEE WILL RECEIVE CONFIRMATION by postcard, telephone, or email IF YOU ARE APPROVED TO ATTEND.

IF YOU DO NO RECEIVE A CONFIRMATION, YOU ARE NOT REGISTERED TO ATTEND.

Arrive promptly at 10:00 am at Parlier Junior High School.

The undersigned understands that the Reality Tour® includes the following scenarios:
(Please circle if you wish to opt out of any portion of the tour)

Peer Pressure Skit Emergency Room / Overdose Funeral Scene Arrest / Prison

Some sections of the Reality Tour® may be emotionally disturbing and parental guidance is a must.

I agree to allow my child/children ______age/ages______
to participate in the Reality Tour® and the self-reported survey data collection included in the program.

To opt out of survey check here: ___

I will accompany my child on the tour. Parent or legal guardian must attend with any child under 18. Please list the name of the legal guardian who will attend: ______

I have read the above and agree not to hold CANDLE, Inc. or its affiliates liable for any claims, damages, demands, actions or lawsuits that could arise as a result of my participation or my minor child’s participation in the Reality Tour®. News photographers may be present at a Reality Tour®.

______
Signature of parent or legal guardian Print name here Date

Address: ______City:______State______Zip______Phone # ______E-mail______

Please list names, ages & grade level of youth attending & include names of adults attending as well:

1.______2. ______3.______

4.______5.______6.______

*** Do you require translation services? If so, which language: Spanish or Hmong.

Funded by the Fresno County Department of Behavioral Health, Substance Abuse Services