Name of Attendee
*
First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
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First Name
Last Name
ER Contact Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
School Currently Attending
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Shirt Size
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Please Select Reality Check Class You Will Be Attending
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Please Select
June 25 (Sulphur High 9th Grade Campus)
July 2 (Sam Houston High School)
July 9 (Westlake High School)
July 16 (Washington-Marion High School)
You DO NOT have to attend the school where the class is being held. All programs will be from 9:00 a.m. until 2:30 p.m.
Waiver & Release
I understand this course is to familiarize students with various skills and that there will be some hands on instruction. By signing below, I authorize my child to participate in the course. I hereby release the Calcasieu Parish Sheriff Gary "Stitch” Guillory, his office, his employees, agents and assigns from any and all liability for any injuries or damages that occurs during the training (including death) and/or for injuries, damages or claims that may result from the utilization or attempted utilization of the training in the future. I agree to indemnify and hold harmless the parties described herein from any and all expenses they incur in defending any claims associated with my child's participation in this program.
Signature of Attendee
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Printed Name of Attendee
First Name
Last Name
Signature of Parent or Guardian
*
Printed Name of Parent
First Name
Last Name
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