Summer Youth Program 2023 – Lee County Sheriff's Office

Student Information

Student Name *

First

Last

Student Date of Birth *

Name of School *

Grade (Only 3rd grade to 9th grade ) *

Parent/Guardian Information

Parents Name *

First

Last

Parents Address *

Address Line 1

City

State

Zip Code

Parents Cell Phone *

Parents Email *

Emergency Contact 1

Emergency First Contact Name *

First

Last

Emergency First Contact Cell Phone *

Emergency First Contact Relationship to Student *

Emergency Contact 2

Emergency Second Contact Name *

First

Last

Emergency Second Contact Cell Phone *

Emergency Second Contact Relationship to Student *

Medical Information

Doctor Name *

Doctor Phone *

Medical Conditions/Allergies *

Medical Limitations and/or Concerns *

Food Allergies *

Each week, the program will be held at:

Oak Hammock Middle School 5321 Tice St Fort Myers, FL

BUS Schedule and Locations

Buses will be provided at the following locations with 8am Pickup and 4pm Drop off

Week	Bus School	Bus Address	Dates	Pick Up	Drop Off
One	Lehigh High School	901 Gunnery RD N, Lehigh Acres	June 19 - June 22, 2023	8am	4pm
Two	Bonita Middle School	10141 W Terry St., Bonita Springs	June 26 - June 29, 2023	8am	4pm
Three	Cypress Lake Middle School	8901 Cypress Lake DR, Fort Myers	July 10 - July 13, 2023	8am	4pm
Four	North Fort Myers Academy of the Arts	1856 Arts Way, NFM,	July 17 - July 20, 2023	8am	4pm

You can only select one week. Please choose a week for your child to attend. All lines with red asterisk (*) must be filled out.

Week # 1 *

June 19-June 22, 2023
Not Selected (child will not attend this week)

Transportation: Please select how your child will get to the Program. *

Parent Drop Off(8 am)/Pickup(3 pm) at Sheriff Youth Summer Program located at Oak Hammock Middle School 5321 Tice St Fort Myers, FL
Bus Pick Up(8 am)/Drop Off(4pm) at Bus Pick Up(8 am)/Drop Off(4pm) at Lehigh Senior HS - 901 Gunnery Rd, Lehigh Acres

Week # 2 *

June 26-June 29, 2023
Not Selected (child will not attend this week)

Transportation: Please select how your child will get to the Program. *

Parent Drop Off(8 am)/Pickup(3 pm) at Sheriff Youth Summer Program located at Oak Hammock Middle School 5321 Tice St Fort Myers, FL
Bus Pick Up(8 am)/Drop Off(4pm) at Bonita Middle school - 10141 W Terry St., Bonita Springs

Week # 3 *

July 10-July 13, 2023
Not Selected (child will not attend this week)

Transportation: Please select how your child will get to the Program. *

Parent Drop Off(8 am)/Pickup(3 pm) at Sheriff Youth Summer Program located at Oak Hammock Middle School 5321 Tice St Fort Myers, FL
Bus Pick Up(8 am)/Drop Off(4pm) at Cypress Lake Middle School - 8901 Cypress Lake Dr, Fort Myers

Week # 4 *

July 17-July 20, 2203
Not Selected (child will not attend this week)

Transportation: Please select how your child will get to the Program. *

Parent Drop Off(8 am)/Pickup(3 pm) at Sheriff Youth Summer Program located at Oak Hammock Middle School 5321 Tice St Fort Myers, FL
Bus Pick Up(8 am)/Drop Off(4pm) at North Fort Myers Academy of the Arts- 1856 Arts Way, NFM,

Important Information Prior to Submitting this Application

Sheriff Carmine Marceno’s Summer Youth Program is FREE of charge. The program will be held at Oak Hammock Middle School each week. Buses will be provided to students if needed, at the locations listed above. Parents may drop off/pick up children at program location. Students currently between 3rd grade and 9th grade who may be interested in participating in the program, are encouraged to apply. Unfortunately, space is limited and the program is based on availability.

This is a four-day summer program, Monday through Thursday. A parent/guardian will be responsible for dropping off and picking up their child on time at the program site or bus stop location. Children are required to wear appropriate, comfortable clothing and closed-toed athletic shoes each day. Lunch and snacks will be provided each day, however, your child may bring their own.

This Summer Youth Program offers a creative and interactive approach geared towards today’s youth. Each child will participate in various law enforcement demonstrations, team building exercises and physical activities. They will learn about the dangers of drugs, bullying, cyber safety, peer pressure, and many other issues encountered by today’s youth on and off campus.

Authorization *

Yes I authorize Lee County Sheriff’s Office to provide emergency medical treatment to my child in my absence and understand that I will be responsible for any expense incurred. I further release Sheriff Carmine Marceno, Lee County Sheriff’s Office and its entities of any wrongful misconduct, personal injury and other liabilities that may occur during the program.

PARENT/GUARDIAN SIGNATURE: *

“The school is neither endorsing nor sponsoring this event, product or service, nor endorsing the views of the sponsoring organization.”

DATE *

PRINT SIGNATURE *

PARTICIPANT WAIVER

THIS IS A WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK FOR THE LEE COUNTY SHERIFF’S OFFICE PROGRAMS/ACTIVITIES. PLEASE READ THIS FORM CAREFULLY and be aware that in signing up and participating in the Lee County Sheriff's Office programs/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor child/ward might sustain as a result of participating in any and all activities connected with and associated with the Lee County Sheriff's Office programs/activities (including transportation services/vehicle operation, when provided). I recognize and acknowledge that there may be certain risks involved in participating in programs/activities, and I voluntarily agree to assume the full risk of any injuries, damages or loss, that my minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I or my minor child/ward may have (or accrue to me or my child/ward) as a result of participating in such program/activity against the Lee County Sheriff’s Office, including their respective officials, officers, employees and volunteers (hereinafter collectively referred as “Parties”). I do hereby fully release and forever discharge the Parties from any and all claims for injuries, damages or loss that my minor child/ward or I may have or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way associated with these programs/activities. I indemnify and hold harmless Sheriff Carmine Marceno, Lee County Sheriff's Office, any of its employees and/or agents from any and all claims from my use of Lee County Sheriff’s Office property or participation in any Lee County Sheriff’s Office programs. I will further indemnify and “hold harmless” the Lee County Sheriff’s Office, it’s employees and/or agents from all costs, expenses and liabilities resulting from any claim brought from my child’s/children’s use of Lee County Sheriff’s Office property and/or participation in Lee County Sheriff’s Office programs to the extent of the Lee County Sheriff’s Office’s liability under general law. This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above and, for myself, my heirs, assigns, and my minor child(ren)’s involvement or participation in the program as provided above. *

I have read and fully understand the above important information, warning of risk, assumption of risk and waiver and release of all claims. If registering via fax, your facsimile signature shall be substitute for and have the same legal effect as an original form signature.

Print Youth Name *

Date *

Parents Signature *

PHOTO, VIDEO, AND SOUND RECORDING RELEASE AND CONSENT

By digitally signing below, I irrevocably give permission to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League, including all of their officers, agents, employees, successors, licensees, and assigns (including any entity Sheriff Marceno, the Lee County Sheriff's Office, or the Sheriff’s Youth Activities League so designates) to take and use photographs, video or sound recordings of myself and/or my minor child for the following project/event:

This is completely voluntary and up to me.

My consent to the use of the photographs, video and sound recordings and my child's and/ or my image, likeness, appearance, and voice is for forever. I will not receive compensation for the use of my and/ or my child's image, likeness, appearance, and voice now or in the future. Sheriff Carmine Marceno, the Lee County Sheriff's Office, the Sheriff’s Youth Activities League may use the photographs, video and sound recordings containing my child's and/or my image, likeness, appearance and voice in any manner or media, including but not limited to use on web pages and social media page. The photographs, video and sound recordings may be used in whole or in part, alone or with other recordings. The photographs, video and sound recordings may be used for any purpose including but not limited to educational, institutional, and informational purposes. Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League have the right and may allow others outside the Lee County Sheriff’s Office and the Sheriff’s Youth ctivities League to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at Sheriff Carmine Marceno, the Lee County Sheriff’s Office’s, and/or the Sheriff’s Youth Activities League’s discretion. All rights, title, and interest whatsoever in the photographs, video and sound recordings belong solely to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League.

I further give permission to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League to use my child's and/or my name, biography, and any other personal data, events, or other material in or in connection with any such uses of the photographs, video and sound recordings.

By digitally signing this form I also understand and agree to the conditions outlined in this photograph, video and sound recording release and consent form. As the parent or legal guardian of the child named below and on behalf of myself and/ or my child, I irrevocably give consent to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League and their respective officers, agents, employees, successors, licensees, and assigns (including any entity Sheriff Marceno, the Lee County Sheriff's Office, or the Sheriff’s Youth Activities League so designates) forever to make use of my child's and my image, likeness, appearance, and voice in photographs, video and sound recordings as described above.

I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this instrument.

I waive any right or claim for compensation of any kind or type whatsoever from Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League for the use, maintenance, release, display, distribution, and publication and promulgated of my child's and my image(s)/photograph(s)/likenesses(s)/depiction(s).

I waive and release Sheriff Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League from any and all claims, demands, damages and/or liability resulting from, or related to the use, release, display, publication, distribution, publication/promulgation of any image(s)/photograph(s)/likenesses(s)/depiction(s), including, without limitation, any such claims and/ or demands made by individuals or entities other me.

My consent to the use of the photographs, video and sound recordings and my child's and/ or my image, likeness, appearance, and voice is for forever. I will not receive compensation for the use of my and/ or my child's image, likeness, appearance, and voice now or in the future. Sheriff Carmine Marceno, the Lee County Sheriff's Office, the Sheriff’s Youth Activities League may use the photographs, video and sound recordings containing my child's and/or my image, likeness, appearance and voice in any manner or media, including but not limited to use on web pages and social media page. The photographs, video and sound recordings may be used in whole or in part, alone or with other recordings. The photographs, video and sound recordings may be used for any purpose including but not limited to educational, institutional, and informational purposes. Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League have the right and may allow others outside the Lee County Sheriff’s Office and the Sheriff’s Youth Activities League to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at Sheriff Carmine Marceno, the Lee County Sheriff’s Office’s, and/or the Sheriff’s Youth Activities League’s discretion. All rights, title, and interest whatsoever in the photographs, video and sound recordings belong solely to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League. I further give permission to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League to use my child's and/or my name, biography, and any other personal data, events, or other material in or in connection with any such uses of the photographs, video and sound recordings. By digitally signing this form I also understand and agree to the conditions outlined in this photograph, video and sound recording release and consent form. As the parent or legal guardian of the child named below and on behalf of myself and/ or my child, I irrevocably give consent to Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League and their respective officers, agents, employees, successors, licensees, and assigns (including any entity Sheriff Marceno, the Lee County Sheriff's Office, or the Sheriff’s Youth Activities League so designates) forever to make use of my child's and my image, likeness, appearance, and voice in photographs, video and sound recordings as described above. I acknowledge that I am fully aware of the contents of this release and am under no disability, duress, or undue influence at the time of my signing of this instrument. I waive any right or claim for compensation of any kind or type whatsoever from Sheriff Carmine Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League for the use, maintenance, release, display, distribution, and publication and promulgated of my child's and my image(s) / photograph(s) / likenesses(s) / depiction(s). I waive and release Sheriff Marceno, the Lee County Sheriff's Office, and the Sheriff’s Youth Activities League from any and all claims, demands, damages and/or liability resulting from, or related to the use, release, display, publication, distribution, publication/promulgation of any image(s)/photograph(s)/likenesses(s)/depiction(s), including, without limitation, any such claims and/ or demands made by individuals or entities other me. *

I INTENTIONALLY, KNOWINGLY AND INTELLIGENTLY INTEND TO WAIVE AND RELEASE, AND HEREBY SO WAIVE AND RELEASE ANY AND ALL RIGHTS, CLAIMS, DEMANDS AND CAUSE(S) OF ACTION OF ANY KIND OR TYPE WHATSOEVER, WHICH I AND/OR MY CHILD MIGHT OTHERWISE HAVE, OR MIGHT HAVE AGAINST SHERIFF CARMINE MARCENO, THE LEE COUNTY SHERIFF'S OFFICE, AND THE SHERIFF’S YOUTH ACTIVITIES LEAGUE IN ANY WAY RESULTING FROM, OR RELATED TO ANY AND ALL ACTS OR OMISSIONS ON THE PART OF SHERIFF CARMINE MARCENO, THE LEE COUNTY SHERIFF'S OFFICE, AND/OR THE SHERIFF’S YOUTH ACTIVITIES LEAGUE WHETHER OR NOT SUCH ACTS OR OMISSIONS WERE/ ARE INTENTIONAL, TORTIOUS OR NEGLIGENT AND ARISING OUT OF THE USE OR PUBLICATION OF PHOTOGRAPHS/IMAGES/VIDEOS/DEPICTIONS/SOUND RECORDINGS OF ME AND/OR MY CHILD.
I DO NOT CONSENT

Print Signature *

Parent Photo Signature *

Photo Child/Minor's Name *

Parent Photo Cell Phone *

Photo Email *

Photo Address *

Address Line 1

City

State

Zip Code