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.
801 East Fourth Street Charlotte, NC 28202 – Telephone Number (980) 314-5182 – Fax Number: (704) 432-1836
MECKLENBURG COUNTY SHERIFF’S OFFICE
REALITY PROGRAM QUESTIONNAIRE
The following questions were created to assess the needs of your child and to determine if the Reality
Program, being offered by the Mecklenburg County Sherriff’s Office, will benefit your child. This information
will help us to address your child’s needs during the Reality tour. **Please print all information other
than signatures. **Spaces are limited and filled on a first come basis. Questionnaire must be
returned by a Referral Source below via fax or postal mail to: Reality Program 801 E. 4th Street
Charlotte, NC 28202 or fax#: (704) 353-1210/704-432-1836
Referral Source must be from one of the following below:
□ School Resource Officer(s)
□ CMS Police Officer(s)
□ Char-Mecklenburg Police Dept
□ Teen Court
□ Dept of Juvenile Justice
□ School Security Officer(s)
Referral Name:
Work Telephone:
Child’s Full Name:
Current Address:
Gender:
□ Male
□ Female
Age:
Race:
Has he/she ever been arrested?
□ Yes
Date of Birth: _____/______/______
□ No
School:
Current Grade Level (Circle One):
4
5
6
Child resides with: □ Both Parents
□ Grandparents
□ Father & Stepmother
7
8
9
□ Mother Only
□ Family Friend
 10
 11
□ Father Only
□ Mother & Stepfather
□ Aunt/Uncle
Parent/Guardian Name: □ Miss □ Ms. □ Mrs. □ Mr.
Mailing Address:
City:
Home/Cell Telephone: (
□ Mother
State:
Zip:
)_________________________ Work Telephone: (
)________________________
□ Father
□ Mother
□ Father
Parent/Guardian Email Address:
What is your child’s grade average (Circle One)?:
How many times has your child skipped school?
A
□ Never
B
C
□ 1 -3
How many times has your child been suspended from school?
D
F
□ 4 -6
□ Never
□7–9
□ 1 -3
□10 or more
□ 4 -6
□7–9
□ 10 or more
Are you concerned your child is currently using drugs?
If Yes, what drugs do you think your child is using?
□ Marijuana
□ Prescription Medications
□ Yes
□ No
□ Crack/Cocaine
□ Ecstasy
□ Heroin
□ LSD (Acid)
□ Other__________________________________
Are you concerned your child is drinking alcohol?
□ Yes
Are you concerned your child is smoking cigarettes?
□ No
□ 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?_____________________
Has your child ever assaulted anyone outside the family? □ Yes
□ No
□ No
If Yes, who was assaulted?: □ Teacher □ Enemy □ Law Enforcement □ Public/Government Official
Has your child ever received professional counseling for his/her behavior?
Are you concerned your child may be in a gang?
□ Yes
□ Yes
□ No
Are you concerned your child is associating with the wrong crowd of people?
Has your child formed different friendships that concern you?
Has your child run away from home?
□ Yes
If Yes, what length of time was he/she gone?
□ No
□ Yes
□ Yes
□ No
□ No
□ No
□ 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)
I, ________________________________________________, parent or guardian (circle one)
Of, ______________________________________________, request that the Mecklenburg Sheriff Office enroll
(Full Name of Juvenile)
The child named above in the Reality Program tour.
Reality Program Consent/Agreement and Release Form
I/We, ___________________________________________________, being the parent(s),
(Print full name of parent, guardian or custodian)
Guardian, or custodian(s) of ________________________________, age _____, along with
(Print full name of child)
The child referenced above, agree to participate in the Reality Program which consists of the tour.
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.
I/We understand that our participation in the Reality Program is voluntary. I/We also understand that
agreement to participate in the program will consist to a Reality Tour.
I/We understand that the program is specifically designed for participants to learn about the realities of
confinement to the jail as well as discuss issues concerning the youth of today. I/We understand that there
will be at least two participants at all times participating in the program inside the Mecklenburg County
Jail. Detention Officers and Deputies from the Sheriff’s Office will be with the participants and
conducting the tour of the jail.
As the parent(s), guardian(s), or custodian(s), in consideration of my child’s participation in the program,
I/We consent to said participation in the Reality Program and agree to discharge and do hereby release
Mecklenburg County, the Charlotte Mecklenburg Board of Education, the City of Charlotte, and all agents
and employees of each, from any and all claims or liability which might arise from any personal injury or
property damage to my child while participating in the program at the Mecklenburg County Jail Central.
As the student being permitted to participate, I consent and agree to say participation.
This being the ________ day of __________________________, 20__.
SIGNED: _________________________________________________
(Full name of parent, guardian, or custodian)
MECKLENBURG COUNTY SHERIFF’S OFFICE
SCHOOL VISIT CONSENT
(Please print except for signatures)
Full Name:
Gender:
□ Male
□ Female
Age:
Race:
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: (
)_________________________
□ Mother
□ Father
Work Phone: (
)________________________
□ Mother
□ Father
Cell Phone: (
)_________________________
□ Mother
□ Father
Cell Phone: (
)________________________
□ 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)
County Sheriff’s Office Reality Program Officer(s) visit my child at school.
As the parent, guardian, or custodian, in conjunction with my child’s participation in the
Reality Program, I consent to said visitation and release of records and agree to discharge
and do hereby release Mecklenburg County, the Charlotte-Mecklenburg Board of Education,
the City of Charlotte and all agents and employees of each, from any and all claims or
liability which might arise from any personal injury or property damage to my child during
this visitation.
Month ___________________________ Day __________, 20_____.
Signature: _______________________________________________
(Full Name of Parent, Guardian or Custodian)
This juvenile completed the Reality Program on: _______/________/_______ (MCJC Usage Only)