Name of Attendee
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Emergency Contact
*
First Name
Last Name
ER Contact Phone Number
*
Please enter a valid phone number.
School Currently Attending
*
Shirt Size
*
Please Select Reality Check Class You Will Be Attending
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Please Select
Sam Houston High School (June 1)
Barbe High School (June 8)
Vinton High School (June 15)
Iowa High School (June 22)
Washington-Marion High School (June 29)
Sulphur High School (July 6)
DeQuincy Middle School (July 13)
You DO NOT have to attend the school where the class is being held. All programs will be from 8:00 a.m. until 4:00 p.m.
Waiver & Release
I understand this course is to familiarize students with various skills and that there will be some hands on instruction. I agree for my child to participate in the program. My child does not have any physical constraints that would prohibit his/her participation in the program. I hereby release Sheriff Tony Mancuso, the Calcasieu Parish Sheriff’s Office, Calcasieu Parish Regional Training Academy, any/all staff and instructors, agents and assigns, for responsibility and/or liability for any damages that occur during the training or for injuries or damages that may result from their attempting to utilize said training in the future.
Signature of Attendee
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Clear
Signature of Parent or Guardian
*
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Submit
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