801 East Fourth Street Charlotte, nc 28202 – Telephone Number (980) 314-5182 – Fax Number: (704) 432-1836

Dear Parent/Guardian,

The Reality Program is an interactive tour, taking youth through each step of the arrest and intake process. There are fifteen slots available per Reality Tour and they are filled on a first come, first serve basis. Enclosed is a Reality Questionnaire, please complete the questionnaire and return it as soon as possible. Our staff uses information from this questionnaire to address specific issues your child may be having during the tour.
The requirements of the Reality Program are you must be a Mecklenburg County Resident. Age ranges from 9-15 years and no prior arrest.
The participation of the child’s parent or guardian is required.
During your visit, parents you will be informed how important it is for The Mecklenburg Sheriff’s Office to provide The Reality Program throughout our communities and schools. You will be educated on the facility and your child’s day experience of The Reality Tour. We will also have on site counseling to discuss the challenges facing the youth of today.

Once you have been scheduled for a tour, you will receive a confirmation letter, as well as a follow up phone call a few days prior to your scheduled tour. If you have any questions, you may contact us at (980)314-5182.

REALITY PROGRAM QUESTIONNAIRE

Referral Source must be from one of the following below: □ School Resource Officer(s) □ CMS Police Officer(s) □ Teen Court □ Char-Mecklenburg Police Dept □ Dept of Juvenile Justice □ School Security Officer(s)

Referral Name:

Work Telephone:

Child’s Full Name:
Current Address:
Gender: □ Male □ Female	Race:	Age:	Date of Birth: _____/______/______
Has he/she ever been arrested? □ Yes □ No

School:
Current Grade Level (Circle One):  4  5  6  7  8  9  10  11
Child resides with: □ Both Parents □ Mother Only □ Father Only □ Aunt/Uncle □ Grandparents □ Family Friend □ Mother & Stepfather □ Father & Stepmother
Parent/Guardian Name: □ Miss □ Ms. □ Mrs. □ Mr.
Mailing Address:
City:	State:	Zip:
Home/Cell Telephone: ( )_________________________ Work Telephone: ( )________________________ □ Mother □ Father □ Mother □ Father
Parent/Guardian Email Address:

What is your child’s grade average (Circle One)?:  A  B  C  D  F

How many times has your child skipped school? □ Never □ 1 -3 □ 4 -6 □ 7 – 9 □10 or more

How many times has your child been suspended from school? □ Never □ 1 -3 □ 4 -6 □ 7 – 9 □ 10 or more

Are you concerned your child is currently using drugs? □ Yes □ No

If Yes, what drugs do you think your child is using? □ Crack/Cocaine □ Ecstasy □ Heroin □ LSD (Acid) □ Marijuana □ Prescription Medications □ Other__________________________________

Are you concerned your child is drinking alcohol? □ Yes □ No

Are you concerned your child is smoking cigarettes? □ Yes □ No

Does your child display any of the following behaviors? □Withdrawn □ Rebellious □ Aggressiveness □ Tiredness □ Depression

How many times have your child been caught stealing? □ Never □ 1 -3 □ 4 -6 □ 7 – 9 □ 10 or more

Does your child have a problem controlling anger, particularly when arguing with parents and/or teachers? □ Yes □ No

Has your child ever assaulted a family member? □Yes Relationship?_____________________ □ No

Has your child ever assaulted anyone outside the family? □ Yes □ No

If Yes, who was assaulted?: □ Teacher □ Enemy □ Law Enforcement □ Public/Government Official

Has your child ever received professional counseling for his/her behavior? □ Yes □ No

Are you concerned your child may be in a gang? □ Yes □ No

Are you concerned your child is associating with the wrong crowd of people? □ Yes □ No

Has your child formed different friendships that concern you? □ Yes □ No

Has your child run away from home? □ Yes □ No

If Yes, what length of time was he/she gone? □ 1 Day □ 2 or more days □ 1week

Describe in detail the problem and/or behaviors for your child (ex: Stealing from persons (stores), Assault (school/home), Disrespectful (school/home), Rebelling

List medical conditions and/or problems (ex: Asthma, Hyperventilation, Seizures, Nosebleeds, Depressions,

Disorders, Compulsive/Impulsive Behaviors, Broken/Sprained Extremities)

(Print full name of parent, guardian or custodian)

(Print full name of child)

We understand that the Reality Program is a program of the Mecklenburg County Sheriff’s Office, in cooperation with Charlotte Mecklenburg Schools, the Charlotte Mecklenburg Police Department, Department of Juvenile Justice and Mecklenburg County Teen Court. The program will involve the child to participate in a tour of Jail Central and an open discussion with other children who are enrolled in the program, which is the Reality Tour. I/We understand that the tour will require both the parent(s) and child to be in attendance and will be held on a designated Saturday. I/We will be notified of the date and time once our acceptance into the program has been confirmed by letter and phone.

This being the ________ day of __________________________, 20__.

MECKLENBURG COUNTY SHERIFF’S OFFICE

SCHOOL VISIT CONSENT

(Please print except for signatures)

Full Name:
Gender: □ Male □ Female	Race:	Age:	Date of Birth:_____/______/______
School:
Current Grade Level (Circle One): 4 5 6 7 8 9 10 11
Parent/Guardian Name: □ Miss □ Ms. □ Mrs. □ Mr.
Daytime Work Phone: ( )_________________________ Work Phone: ( )________________________ □ Mother □ Father □ Mother □ Father
Cell Phone: ( )_________________________ Cell Phone: ( )________________________ □ Mother □ Father □ Mother □ Father

Consent and Release

I, _____________________________________________________, as a parent, guardian or

(Print Full Name of Parent, Guardian or Custodian)
Custodian of ____________________________________________, request that a Mecklenburg

(Print full name of Child)

Month ___________________________ Day __________, 20_____.