Levy County Prevention Coalition

2025 - 2026 Youth Enrichment Program Registration

List Names of Additional People Authorized to Pick up Youth:

Please list Emergency Contacts

By signing this form, you indicate the desire for your child to participate in the Levy County Prevention Coalition's ACHIEVE Enrichment Program. You also indicate that you understand that this is an educational and enrichment program not a "childcare" program. You should discuss with your child that violations of the program rules may result in their withdrawal from the program.

Form: PRG-YOUTH-ENRICH-01 Last Updated: 07/16/2023

LCPC Youth Enrichment Programs

Youth Information, Photo and Field Trip Release

Document Release: 

By signing below, I authorize the School Board of Levy County to release the information listed below to the Levy County Prevention Coalition for the 2025-2026 youth program year. Any and All School Records Related to My Child Examples Include: Report Cards, IEP's, Discipline Reports, Accommodations, Etc. This release shall be valid from the date on which it was signed and remain in effect until 08/30/2028. Please Note: The Document Release is a requirement for your child to be enrolled in any LCPC Youth programs. All information is securely stored and kept confidential.

Photo Release:

By selecting an option below, I will grant or not grant permission to take photos.  Some examples of use of photographs and videos include:Photo/Video of youth working with staff, completing projects, etc. Examples of Use: Facebook Posts, Newspapers, Newsletters, Reports.

Field Trip Permission:

By signing below, you give permission to take your child on various field trips during the 2025-26 program year. This signed agreement absolves all staff, Levy County Prevention Coalition, Inc. any and all members of its governing boards, and all other partnering organizations of any responsibility for the safety, welfare, health and well-being of the youth named above, beyond such matters as may be called reasonable care for youth in the custody of program staff and subject to the staff's clear instruction, and assumes personally and exclusively all responsibility and liability for accident, injury, etc., which may occur to the above named youth during the dates specified below.

You will be notified prior to any planned field trips.  You have the right to notify staff of any field trip you wish your child to refrain from participating in.  Field Trip modes of transportation may include:  School Bus, Charter Bus, Company Vehicles, Van, Walking.

 Field Trip Release Expiration Date: 08/31/2026

By signing below, I agree to the terms and conditions of the document release, photo release and field trip release.

Form: PRG-YOUTH-ENRICH-02 Last Updated: 07/19/2024

LCPC Youth Enrichment Programs

Transportation Agreement - Waiver & Release

I hereby give permission to Levy County Prevention Coalition, Inc., to transport my child, to/from LCPC's Youth Program for the remainder of the program year, expiring 08/31/2026.

I understand that by allowing Levy County Prevention Coalition, Inc. to transport my child to/from the above-mentioned program, I agree to release the Levy County Prevention Coalition, Inc. & Tartu Foundation, Inc., its agents and employees and contractors from and against any and all liability, loss, damages, claims or actions to the maximum extent permissible by the law, arising out of such transportation.

Please call our office at 352-328-3540 if your child will have different pick-up or drop-off locations based on split custody.

If your child will always be a car rider, you can leave the pick-up and drop-off fields blank.

Consent and Notice for Text Message Authorization

Levy County Prevention Coalition's Youth programs utilize various forms of communication to notify parents with information about activities regarding their children.

LCPC's Youth program uses short message service (SMS), otherwise known as "text messaging" or "texting" via cell phone as one form of communication. LCPC will use various text messaging apps which enables parents to securely track their child's bus location, both to and from school and inform when their child arrives home. Parents understand and agree that LCPC's Youth program will not pay for any costs to parents associated with the sending or reception of messages to or from LCPC's Youth program. Parents agree to receive and/or obtain the selected text messages from LCPC's Youth program via an automatic text messaging system. Parents agree that in the event their cell phone number changes that they will inform LCPC's Youth program director in writing with the new cell phone number.

I have read, understand and agree to all information, terms and conditions above:

Form: PRG-YOUTH-ENRICH-03 Last Updated: 08/11/2025

LCPC Youth Enrichment Programs

Health History and Medication Form

Parent/Guardian: Please follow the instructions below. Attach additional information if needed. Complete all pages of this form. Return the entire form with youth's registration packet by the requested date.

Form: PRG-YOUTH-ENRICH-04, Pg 1 of 2

LCPC Youth Enrichment Programs

Health History and Medication Form

The following non-perscription medications may be stocked by the program and are used on an as needed basis to manage illness and injury. Please select the medications your youth should NOT be given. Failure to select an item indicates program staff may give the item to your child. 

Perscription Medications 

Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Medication must be sent each Monday of each week and MUST be in the original packaging/bottle, showing the youth's name, type of medication, dosage information, and other pertinent information required to properly assist your youth. By sending medication and signing this form, you agree to allow program staff to provide your child access to their medication and administer the medication per the packaging/your written instructions below. 

What have we forgotten to ask?

Parent/Guardian Authorization for Health Care:

This health history is correct and accurately reflects the health status of the youth to whom it pertains.  The person described has permission to participate in all youth programs except as noted by me and/or an examining physician.  I give permission to the physician selected by the program to order x-rays, routine tests, and treament related to the health of my youth in emergency situations.  If I and/or listed emergency contacts cannot be reached in an emergency, I give permission to the physician to hospitalize, secure proper treament form and order injection, anesthesia, or surgery for this youth.  I understand the information on this form will be shared on a "need to know" basis with program staff.  I give permission to photocopy this form.  In addition, in the event of an emergency, the program has permission to obtain a copy of my youth's health record from providers who treat my youth and these providers may talk with the program's staff about my youth's health status. 

Form: PRG-YOUTH-ENRICH-04, Pg. 2 of 2

LCPC Youth Enrichment Programs

Medication Authorization and Release

(Parent/Guardian name) authorize Levy County Prevention Coalition, Inc. personnel to administer listed medication to my child in the manner described by me in the Medical History Form. I release any liability in relation to the administration of this medication. I also acknowledge that I, the parent/guardian, have given the first dose of this medication without any allergic or unexpected reactions.

Furthermore, I understand that medication must be sent each Monday of each week and MUST be in the original packaging/bottle, showing the child's name, type of medication, dosage information, etc.

This authorization and release shall be valid from the signature date below and will expire on 08/31/2026.

Please Note: All information is securely stored and kept confidential.

Form: PRG-YOUTH-ENRICH-05 Last Updated: 08/04/2024

Contract of Release and Waiver, Assumption of Risk, and Indemnification
FOR: Levy County Prevention Coalition & Tartu Foundation

THIS IS A COMPLETE LIABILITY RELEASE – BE SURE YOU UNDERSTAND THIS DOCUMENT BEFORE SIGNING

INTRODUCTION: Levy County Prevention Coalition, Tartu Foundation, public and private landowners, public and private facility owners, vehicle owners and equipment owners (hereinafter collectively “Releasees”) offer limited protection for Enrichment Programs (all releasee programs you enroll your child into) (hereinafter collectively, “Event”). You (hereinafter collectively, “Releasor”, “I”, or “me”, which terms shall also include Releasor’s parent and guardian if Releasor is under 18 years of age) could suffer personal injury, including DEATH, and property damage at this event or on the adjacent premises. You are being asked to sign this contract in consideration of being allowed to enter the event. Event activities include but are not limited to Water Activities, Swimming, Fishing, indoor and outdoor recreation, indoor and outdoor academic and personal enrichment activities and all other activities conducted during the Enrichment Programs. This contract covers any and all injuries and damages sustained by you at this event, anytime within 365 days from the date you signed this contract.

WHO BENEFITS FROM THIS CONTRACT?: The portion of this agreement, which permits you entry into the event, runs to your benefit and allows you to attend the event. The portion of this contract in which you agree to release, waiver, assume risk and indemnify runs to the benefit of this event, its owners, tenants, operators, promoters, partners, corporate entities, shareholders, members, directors, and officers of any entity, and to the benefit of all the others participating in this event, including yourself.

WHO IS BOUND BY THIS CONTRACT?: Until you sign your name to this document, it is an offer, which you can accept or reject. By signing, you are accepting all the terms of this contract and you are binding yourself, your heirs, your assigns, this event, its owners, its operators, its agents and its sponsor to those terms.

PREMISES COVERED: The premises referred to herein shall include, but not be limited to all the natural land, bodies of water, trees, fences, walls, and perimeter, all roadways and parking lots, all areas of ingress and egress, all buildings, restrooms and facilities, and any other parts and portions of these and adjacent premises inside the boundaries of the state of Florida.

SITUATIONS COVERED: The type of accidents, risks, and dangers which can cause you a personal injury including DEATH and/or property damage, and which are intended to be covered by this Contract of Release and Waiver, and Assumption of Risk, and Indemnification; include but are not limited to:
1. Injuries caused by nature including but not limited to water, wild animals, plants, hidden ground openings, sliding rocks, and trees;
2. Entering, exiting, servicing, driving, steering, riding, sitting in, colliding, loading or unloading, and/or crashing a vehicle;
3. Being struck, contacted, injured or being in fear of injury, even if you are a spectator, laboring or competing, by any animal, vehicle, liquid, gas, fireworks, explosives, bullets or other projectiles, dirt, blacktop, stone and/or clay;
4. Being injured by rescue or attempt to rescue, whether such rescue is made on the premises or adjacent to the premises;
5. Eating, consuming, and digesting food or beverages, even if said food or beverage is defective or harmful;
6. Being injured as a result of a defective or harmful condition in some product, place, equipment, and/or services supplied to you for your use;
7. Being injured as a result of failing to be supplied some necessary equipment by releasees;
8. Being injured as a result of improper operation of a vehicle by releasees;
9. Being injured as a result of riding as a passenger on a vehicle improperly operated by releasees;
10. Being injured as a result of negligent actions by releasees;
11. For all such injuries occurring within or adjacent to these premises.

RELEASE AND WAIVER: By signing at the bottom of the page, you are releasing this event, its owners, its operators, its officials, its sanctioning organization, its sponsors, and all others participating in this event for any personal injury including DEATH and/or property damage sustained by you while on the premises. The law gives you, your dependents, your assigns, and/or your estate, potential rights to sue this event, its owners, its operators and the others signing this release with whom you are participating in this event, if you suffer a loss at the event. By signing this contract, you are waiving those rights and promising not to sue the event, its owners, and sponsors and other event participants for your personal injury and property damage, whether caused by your negligence, the negligence of event owners and/or operators or the negligence of others. Even if your loss is entirely the fault of the releasees, you are releasing them from any and all responsibility and liability. You are signing a complete liability release.

INDEMNIFICATION: By signing at the bottom, you are also indemnifying this event, its owners, its operators. That means that if they suffer any kind of loss or debt, which is due in whole, or in part to your fault, they can seek reimbursement from you for that portion of their loss or debt, which is due to your fault, even if they are partially at fault, too.

ASSUMPTION OF RISK: Preparation for, participation in, and observation of this event can be very dangerous activities, which can injure your person and damage your property, or even cause DEATH. Although you are aware of those risks, you are still voluntarily going ahead and entering these dangerous premises and participating in the event. That means that you are “assuming the risk” inherent in entering and being a part of the event and, if you suffer a loss because of those risks, you will not be allowed to make a claim against this event, its owners, sponsors, operators and other participants. If you become aware of any dangers, risks, or defects, you do not wish to assume, you are responsible for removing yourself from the premises and are still “assuming the risk” while removing yourself from the premises.

BY SIGNING YOUR NAME AT THE BOTTOM, you hereby agree that you have read or have been given opportunity to read this contract and you agree that you understand it. If any paragraph or provision of this contract is deemed illegal, the rest of the document shall stand in full force and effect.

RULES: By signing this agreement, you hereby agree to follow any and all the event’s rules, regulations and responsibilities, printed, published or posted, together with those rules and practices which are the custom of the event.

COPIES OF THIS CONTRACT ARE AVAILABLE TO YOU: Upon request, you will be given a copy of this agreement.

ARBITRATION: Any dispute, controversy or claim arising out of or in connection with this Agreement or any breach or alleged breach hereof shall, upon the request of any party involved, be submitted to, and settled by, arbitration in Levy County, Florida, pursuant to the commercial arbitration rules then in effect of the American Arbitration Association (or at any other time or place or under any other form of arbitration mutually acceptable to the parties involved). Any award rendered shall be final and conclusive upon the parties and a judgement thereon may be entered in a court of competent jurisdiction. The expenses of arbitration shall be born equally by the parties to the arbitration, provided that each party shall pay for and bear the cost of its own experts, evidence and attorneys’ fees, except that in the discretion of the arbitrator any award may include the attorney’s fees of a party if the arbitrator expressly determines that the party against whom such award is entered has caused the dispute, controversy or claim to be submitted to arbitration as a dilatory tactic or in bad faith.

CHOICE OF LAW: All questions concerning the construction, validity, and interpretation of this Contract and the performance of the obligations imposed hereby shall be governed by the internal law, not the law of conflicts, of the State of Florida."

NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN: YOU AGREE YOU HAVE READ THIS AGREEMENT COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY (“EVENT”).

"LCPC Enrichment Programs Agreement – 2025/2026
Enrichment Program Waiver & Release

IN CONSIDERATION OF the risk and injury that exists while participating in LCPC Enrichment Programs and all activities, (include but not limited to, Swimming, Fishing, all other indoor and outdoor recreation, indoor and outdoor academic and personal enrichment activities) (hereinafter the “Activity”); and IN CONSIDERATION OF my desire to participate in said Activity and being given the right to participate in the same;

I HEREBY for myself, my heirs, executors, administrators, assigns, or personal representatives (hereinafter collectively, “Releasor,” “I” or “me”, which terms shall also include Releasor’s parents and guardian if Releasor is under 18 years of age), knowingly and voluntarily enter into this WAIVER AND RELEASE OF LIABILITY and hereby waive any and all rights, claims or causes or action of any kind arising out of my participation in the Activity; and I HEREBY release and forever discharge Levy County Prevention Coalition, associated contractors, supporting organizations, volunteers, public and private land owners, public and private facility owners, vehicle owners, and equipment owners, located at all LCPC Enrichment Program sites, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns (collectively “Releasees”), from any physical or psychological injury that I may suffer as a direct result of my participation in the aforementioned Activity.

I AM VOLUNTARILY PARTICIPATING IN THE AFORMENTIONED ACTIVITY AND I AM PARTICIPATING IN THE ACTIVITY ENTIRELY AT MY OWN RISK. I AM AWARE OF THE RISKS ASSOCIATED WITH PARTICIPATING IN THIS ACTIVITY, WHICH MAY INCLUDE, BUT ARE NOT LIMITED TO: PHYSICAL OR PSYCHOLOGICAL INJURY, PAIN, SUFFERING, ILLNESS, DISGIFUREMENT, TEMPORARY OR PERMANENT DISABILITY (INCLUDING PARALYSIS), ECONOMIC OR EMOTIONAL LOSS, AND DEATH. I UNDERSTAND THAT THESE INJURIES OR OUTCOMES MAY ARISE FROM MY OWN OR OTHERS’ NEGLIGENCE, CONDITIONS RELATED TO TRAVEL TO AND FROM THE ACTIVITY, OR FROM CONDITIONS AT THE ACTIVITY LOCATION(S). NONETHELESS, I ASSUME ALL RELATED RISKS, BOTH KNOWN AND UNKNOWN TO ME, OF MY PARTICIPATION IN THIS ACTIVITY.

I FURTHER AGREE to indemnify, defend and hold harmless the Releasees against any and all claims, suits or actions of any kind whatsoever for liability, damages, compensation or otherwise brought by me or anyone on my behalf, including attorney’s fees and any related costs.

I FURTHER ACKNOWLEDGE that Releasees are not responsible for errors, omissions, acts or failures to act of any party or entity conducting a specific event or activity on behalf of Releasees. In the event that I should require medical care or treatment, I authorize Levy County Prevention Coalition to provide all emergency medical care deemed necessary, including but not limited to, first aid, CPR, the use of AEDs, emergency medical transport, and sharing of medical information with medical personnel. I further agree to assume all costs involved and agree to be financially responsible for any costs incurred as a result of such treatment. I am aware and understand that I should carry my own health insurance.

I FURTHER ACKNOWLEDGE that this Activity may involve a test of a person’s physical and mental limits and may carry with it potential for death, serious injury, and property loss. I agree not to participate in the Activity unless I am medically able and properly trained, and I agree to abide by the decision of the Levy County Prevention Coalition official or agent, regarding my approval to participate in the Activity.

I hereby acknowledge that I have carefully read this “enrichment program waiver and release” and fully understand that it is a release of liability. I expressly agree to release and discharge Levy County Prevention Coalition, associated contractors, public and private landowners, public and private facility owners, vehicle owners, and equipment owners and all of its affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors, and assigns, from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against Levy County Prevention Coalition, associated contracted, private landowners, vehicle owners (includes ATV/UTV vehicles) and equipment owners for personal injury or property damage.

To the extent that statue or case law does not prohibit releases for ordinary negligence, this release is also for such negligence on the part of Levy County Prevention Coalition, associated contractors, public and private landowners, public and private facility owners, vehicle owners, equipment operators, its agents, and employees.

I agree that this Release shall be governed for all purposes by Florida law, without regard to any conflict of law principles. This waiver and release of liability shall remain in effect for the duration of my participation in the activity, during this initial and all subsequent events of participation and is valid for 365 days from the time in which it was signed.

THIS AGREEMENT was entered into at arm’s-length, without duress or coercion, and is to be interpreted as an agreement between two parties of equal bargaining strength. Both Releasor and Levy County Prevention Coalition, associated contractors, public and private landowners, public and private facility owners, vehicle owners and equipment owners agree that this agreement is clear and unambiguous as to its terms, and that no other evidence shall be used or admitted to alter or explain the terms of this agreement, but that it will be interpreted based on the language in accordance with the purposes for which it is entered into.

In the event that any provision contained within this Release of Liability shall be deemed to be severable or invalid, or if any term, condition, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, the remainder of this agreement shall remain in full force and effect. If a court should find that any provision of this agreement to be invalid or unenforceable, but that by limiting said provision it would become valid and enforceable, then said provision shall be deemed to be written, construed and enforced as so limited.

Parents and guardians must sign multiple release forms – “Contract of Release and Waiver, Assumption of Risk, and Indemnification” and “LCPC Enrichment Programs; Complete Liability Release for Minors”. Signing this form does not diminish the “Contract of Release and Waiver, Assumption of Risk, and Indemnification”.

Complete Liability Release for Minors

NOTICE TO THE MINOR CHILD’S NATURAL GUARDIAN: READ THIS COMPLETE LIABILITY RELEASE FOR MINORS AGREEMENT COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR CHILD ENGAGE IN POTENTIALLY DANGEROUS ACTIVITIES. You are agreeing that, even if Levy County Prevention Coalition, associated public and private landowners, public and private facility owners, vehicle owners and equipment owners uses reasonable care in providing this activity, there is a chance your child may be seriously injured or killed by participating in this activity because there are certain dangers inherent in the activity which cannot be avoided or eliminated.

By signing this form, you are giving up your child’s right and your right to recover from Levy County Prevention Coalition and all associated parties in a lawsuit for any personal injury, including DEATH, to your child or any property damage that results from the risks that are a natural part of the activity. You have the right to refuse to sign this form, and Levy County Prevention Coalition has the right to refuse to let your child participate if you do not sign this form.

In the event that any provision contained within the release forms shall be deemed to be severable or invalid, or if any term, conditions, phrase or portion of this agreement shall be determined to be unlawful or otherwise unenforceable, all other terms, conditions, phrases or portions of the agreement shall remain in full force and effect.

You can, at any time, discontinue your child’s participation in any LCPC Enrichment Programs by not sending them to the program."

Dear Levy County School Board Members, Schools Superintendent and Community Stakeholders,

I’m writing you today to ask for your continued support of the programs offered by the Levy County Prevention Coalition. These programs include mentoring, afterschool, weekend, and summer programs aimed at decreasing youth substance use and mental health stressors while enhancing protective factors. Continued and increased support of these programs will bolster the commitment to helping children and families in our community.

We count on the resources provided by the Levy County Prevention Coalition to keep young people safe and healthy, inspire them to learn, and give working parents peace of mind. We encourage you to actively remove roadblocks that lead to increased operating costs and frustration. Furthermore, we ask that you that you recognize our school facilities are often the major focal points in each of our resource limited communities. Our schools should be vibrant community minded centers that aim to ensure our youth and families have access to any and all resources possible, during and outside of the school day. Levy County is unique because we do not allow bureaucratic minded individuals to stop common sense ways of operating and providing our youth unique opportunities. Levy County Prevention Coalition has sourced most of its funding from outside of Levy County, ensuring their organization is bringing as much into our community as possible.

4 in 5 parents report that afterschool programs help them keep their jobs and provide for their families. Kids in afterschool and summer programs have better grades, are more likely to graduate, and even earn higher incomes with better jobs as adults. Every $1 spent on these programs saves taxpayers $3, and 85% of voters want you to invest more–not less–in afterschool and summer programs. Our community, and our economy, can’t afford to lose afterschool and summer programs due to poor communication or lack of community minded partnerships. We’re already far behind in meeting the need. For every child in a program, 4 are waiting to get in.

Your previous support and investment in the programs offered by Levy County Prevention Coalition is making an incredible impact. Youth are getting the math and reading enrichment they need, healthy physical activity, nutritious snacks, and hands-on, engaging activities. As young people struggle with mental health challenges and continue to catch up in learning, these supports are more important than ever. New data shows that mentoring and out-of-school-time programs help students engage in their learning and combat chronic absenteeism. Furthermore, thanks to the Coalition’s Achieve program, middle and high school credit retrieval is at an all-time high, bolstering Levy’s graduation rate.

We ask that you wholeheartedly support these programs and in doing so, ensure our children have access to quality mentoring, afterschool, weekend and summer enrichment programs. School-based administrators must be community-minded and willing to actively support community-based organizations, aiming to do the best possible job for our communities, families and students.
We hope you prioritize young people and families as you determine the level of support you will give to these very important programs. Thank you for supporting our youth and I look forward to your response.

Sincerely,