Choose Today. Attend Beaver County Reality Tour. Change Tomorrow. Be the biggest influence in your child’s life.

Reality Tour® METH

Alcohol Weed

Tour will be held from 6-9 PM (arrive at 5:45) at

Tobacco

Chippewa Evangelical Free Church * 239 Braun Road Beaver Falls, PA 15010 *NEW LOCATION

Pharm Parties OTC

Important Registration Information: Registration is required. There is a $5 registration fee/person . Scholarships available for those in need. Your registration will be confirmed by telephone or email. Once you receive confirmation, please arrive promptly at 5:45 PM at the Chippewa Evangelical Free Church on your selected date. Some portions of Reality Tour® may be intense, and parental guidance is a must. Questions? Call CHC 724-432-3474 or email us at [email protected] For more information or to download and print additional registration forms: www.CommunityHealthChallenge.org Reality Tour 2012-2013 Registration/Waiver Form Please indicate your preferred date: NOTE:

if your preferred date is booked, you will be offered another open tour date

___ November 8, 2012 ___ February 7, 2013

___ December 6, 2012 ___ March 14, 2013

List all attending: I permit my child/children listed to participate in Reality Tour. _________________________ A parent or guardian must attend with any child under 18. Reality Tour is appropriate for children age 10 and older and __________________________ must be accompanied by a parent.

Age: ____ ____

I have read the information on this form 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 Reality Tour. ____ (check if additional names on reverse) # of persons attending___@ $5 EACH=$_____

□Parent □Guardian_______________________________ Signature ________________________________ Print Name

______ Date

________________________________________ Address ____________________ City/Zip

__________________ Phone

________________________________________ Email

Some scenes may be intense . Please circle if you chose to opt out: Peer Pressure Skit Funeral Scene

ER/Overdose Arrest/Prison

Please make checks payable and mail to: Community Health Challenge 1272 Mars Evans City Road, Ste 102 Evans City, PA 16033 Educators are eligible for ACT 48 credits. PDE# ______________________

Reality Tour is a national project of CANDLE, Inc. All rights reserved.