I am the parent/grandparent/legal guardian of the person identified below, a Lakota YouthStay participant, who has a medical condition that requires that he/she take prescription medication. Throughout the course of the year, he/she also may take over-the-counter medications as needed and indicated below.

Because I am unable to be with him/her at the time he/she may need to take prescription and/or over-the-counter medication, I give the YouthStay program director, authorized YouthStay advisors/volunteers or adult member of the host family permission to administer the following medication to my child, grandchild and/or legal ward according to the instructions provided by his/her medical provider:

My child/grandchild/legal ward has permission to take the following medications in case of sickness, injury, or accident: (check all that apply)

I have completed the Parental Permission Form and will submit a letter of good health no later than 6/30 for my child/grandchild/legal ward to participate in the Lakota YouthStay program. I have also completed the Permission Form to seek medical care in the case of illness, injury or accident. I understand I am solely responsible for assuring that all medications provided to the Lakota YouthStay program director, volunteer chaperones and host families are not expired.

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