CANDLE, Inc



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New Site: Monarch Place, 100 Brugh Ave., Butler, PA 16001

Mail to: 100 Brugh Ave., Butler, PA 16001

6 p.m. – 9 p.m. Arrive—5:45 p.m.

Must indicate 1st & 2nd choice of dates to attend Reality Tour®

TIP: register online PREFERRED !

2018: Sept 10___ Oct. 8___ Nov 12___ Dec 10___

2019: Feb. 11___ Mar.11____ Apr. 8____ May 13___

School District: _______________Name of School(s): ______________

Option: register online at

I agree to allow my child/children listed below 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 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 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.

X _____________

Signature of parent or legal guardian Print name here Date

Your signature on this form indicates you understand that the Reality Tour® includes the following: (Circle to opt out)

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

Address: City: State: Zip:

Phone #: E-mail:

Enter name, age & grade of youth. List ALL adults attending as well:

1. 3. 5.

2. 4. 6.

Check here if confirmation of attendance is Mandated or required by school or court

phone: 724-679-6612 to register & MAKE REQUIRED PAYMENT & CONFIRMATION ARRANGEMENTS (NO EXCEPTIONS)

‘I Promise’ Hoodies & T-shirts

Wear your drug-free promise!

Adult sizes: Small Medium Large

XL (+ $2.00) XXL (+ $2.00)

Hoodie—$30.00 Size(s) Color(s)

(black or gray)

T-Shirt—$15.00 Size(s) (white Only)

Total Order $ (make checks payable to CANDLE, Inc.)

Must pay in advance

Ready for pickup at Reality Tour®

Registration = $5.00 (each adult & each child)

(No charge if on free or reduced Lunch. write ‘lunch’)

Total persons attending x $5.00 = $

Donation to support the Reality Tour = $ ______

(Tax deductible)

¡% Reserve a Family Health Policy Home Drug Test Kit - Prepay $15. Plus enroll to rece□ Reserve a ‘Family Health Policy’ Home Drug Test Kit - Prepay $15. Plus enroll to receive our random notice of when to test.

Pickup test kit at Tour. #Test kits @ $15.00 ea. ___Payment $____

Total amount enclosed = $___________

» No refunds for no shows and cancellations «

Mail Now! Make checks payable to: CANDLE, Inc.

Mail to: 100 Brugh Ave., Butler, PA 16001

For more information phone: 724-679-6612

VISIT E-mail RealityTour@

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