Personal Information
Childs’ Last Name ______First Name ______
Parent Last Name______First Name______
Date of Birth: ______Age _____ School: ______Grade: ______(Next School Year)
Address: ______
Home Phone: ______Cell Phone ______
Email Address: ______
Emergency Contact Person: ______Phone:______
Relationship of emergency contact: ______
Address: (if different from above) ______
Home Phone: ______Cell Phone ______
Medical Information
Doctor Name: ______Phone ______
Medical Conditions/Allergies ______
Medical Limitations and/or concerns: ______
Site Locations and Dates (PLACE AN “X” NEXT TO “ONE” SITE ONLY !!!!)
______Site One: Three Oaks Middle………………..June 5th - June 8th, 2017
______Site Two: Lehigh Acres Middle…. .…………June 12th - June 15th, 2017
______Site Three: Challenger Middle………….……...June 19th - June 22nd, 2017
______Site Four: Gulf Middle...... June 26th - June 29th, 2017
______Site Five: Mariner Middle……………………..July 3rd - July 5th-7th, 2017
______Site Six: Caloosa Middle…………...…….....July 10th - July 13th, 2017
______Site Seven: Oak Hammock Middle...…………..July 17th - July 20th, 2017
______Site Eight: Ft. Myers Middle Academy………..July 24th- July 27th, 2017
______Site Nine: N. Ft. Myers Academy for Arts…..July 31st- August 3rd, 2017
Important Information prior to submitting this application
The Sheriff’s Summer Youth Program is FREE of charge. Anyone between the ages of 11-13, who may be interested in participating in the program, is encouraged to apply. Unfortunately, the seats are limited and all who apply will not be selected to participate in the program as it is based on the availability. If your child is selected to participate in the SYP, you will receive a phone call the week prior to the pre-registration date.
The program is a four-day program, Monday through Thursday, from 8:00 am to 3:00 p.m. Parents or their designee will be responsible for dropping off and picking up their child on time at the program site. Children are required to wear appropriate comfortable clothing and closed-toed athletic shoes each day. Each child will need to bring a lunch/drink Monday through Wednesday. Lunch will be provided on Thursday.
The Summer Youth Program / SYP offers a creative, interactive, intense and fresh approach geared for youth today, who are faced with handling problems and making real life decisions. Each child will participate in various law enforcement demonstrations and will gain knowledge on nutrition, physical fitness and guidance on making healthy choices.
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 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: ______DATE: ______
“The school is neither endorsing nor sponsoring this event, product or service, nor endorsing the views of the sponsoring organization.”