Site: JB’S Bright Beginnings (Formerly Scull Elementary School), 780 Brush Hill Road, North Huntingdon, PA 15642
6:30pm-9pm Arrive: 6:00
Indicate 1st & 2nd choice of dates to attend Reality Tour
2017
October __10
2018
November __14_ December _12_
February 13 March 13 April __10__
School District: __________________________
Name of School: ________________________________
I agree to allow my child/children _____________________________________ age/ages___________________ to
participate in CANDLE, Inc.’s Reality Tour program & surveys. I understand the program is appropriate for children
ages 10-18 and the child’s parent / legal guardian must be present.
A.) I will
accompany my child.
Or B.) Name child’s legal guardian if attending:____________________
I have read the above and agree not to hold Norwin Lions Club, JB’s Bright Beginnings, 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 Reality Tour. I am aware news cameras and/or reporters may be present.
Some sections of Reality Tour are emotionally charged and I understand parental guidance is a must.
Your signature on this form indicates you understand that the Reality Tour includes the following: (Circle to opt out)
Peer Pressure
X
Emergency Room / Overdose
S IGNATURE OF PARENT OR LEGAL GUARDIAN
Address:
Phone #
X
E-mail
City
3.
4.
•
Surveys
X
State
D ATE
Zip
List all adults attending as well:
5.
6.
NOTE : SCHOOL OR COURT REFERRALS MUST PHONE 724-679-6612 FIRST TO REGISTER AND ARRANGE PAYMENT.
NO EXCEPTIONS!
C HECK HERE IF CONFIRMATION OF ATTENDANCE IS REQUIRED BY SCHOOL OR COURT ?
R EGISTRATION = $5.00 ( EACH ADULT & EACH CHILD )
(N O CHARGE IF ON FREE OR REDUCED L UNCH . WRITE ‘ LUNCH ’)
T OTAL PERSONS ATTENDING
X $5.00 = $
Donation to support the Reality Tour = $
(Tax deductible)
______
Total amount enclosed = $
Make checks payable to: Norwin Reality Tour
Mail to: Norwin Reality Tour c/o Darcy Leoni
1097 Nottingham Court
North Huntingdon, PA 15642
Note: Your reservation date will be confirmed by an email one
week prior to tour date.
38 Norwin
Arrest / Prison
P RINT NAME HERE
Enter name, age & grade of youth.
1.
2.
Funeral Scene
Sponsored
by
Norwin Lions Club
A s o u r f a c i l i t y i s n o t h a n d i c a p a c c e s s ib le , if
needed we can refer you to the Greensburg
Courthouse site. Please email
[email protected]
for further information.
For more information phone: 412-956-0440
VISIT www.RealityTour.org
E-mail [email protected]
Reality Tour is a national project of the nonprofit
CANDLE, Inc. www.RealityTour.org