Permissions, Declarations and Endorsements

We, the parents/legal guardians of the above named applicant who have the sole and legal right to make the decisions on the health and care of the applicant, do release the Lakota YouthStay Program and all its agents, the host families, volunteers, One Spirit and its agents, volunteers and employees from all liability and grant permission as noted of the following while our son/daughter/ward is participating as a YouthStay program participant:

• In the event of accident or sickness, I/we authorize any YouthStay host/family member of host, director, staff, volunteer, Advisory Committee member, One Spirit staff or member to select the appropriate medical facility and physician(s)/dentist(s) to provide urgent/emergency treatment.
• I give permission for any operation, administration of anesthetic or blood transfusion that a licensed medical practitioner may deem necessary or advisable in any urgent/emergency situation.
• I further consent to any medical or surgical treatment by a licensed physician, surgeon or dentist that might be required for any emergency situation.

I agree to hold harmless One Spirit and the Lakota YouthStay Program as well as its directors, staff, volunteers, Advisory Committee members, hosts and host family members, and authorized chaperones for any intervention in an emergency situation regardless of the final outcome. 

I agree to provide the Lakota YouthStay program with a dated and signed letter from my child’s physician stating he/she is in good health and a proof of a physical exam done within the last year. I agree to provide an additional letter of good health from an MD or NP within 3 weeks of the departure date. I understand my child will not be permitted to participate in the YouthStay program unless this information is submitted prior to the departure date.

In consideration of the acceptance and participation of the above named applicant in the YouthStay program, we, his/her parents or legal guardians, to the full extent permitted by law, hereby release and agree to defend, hold harmless and indemnify all hosts and members of their families and all staff, volunteers, officers, directors, committee members of the Lakota YouthStay program, West Medford Community Center and One Spirit from any or all liability for any loss, property damage, personal injury, or death including any such liability that may arise out of negligent act or omission, excepting gross negligence or intentional conduct, of any such persons or entities, which may be suffered or claimed by such applicant, parent or guardian before, during or after or as a result of the participation by the applicant in the Lakota YouthStay program including travel from and to the participant’s home.  As the undersigned parents or legal guardians of the applicant:

• We agree that the applicant may participate in the Lakota YouthStay Program.
• We have read and understood the Program Rules and Conditions of the Program and agree to abide by them.
• We have read and understood the Statement of Conduct for Working with Youth and we understand the all those involved with the YouthStay program including hosts are expected to have read and understood this statement.
• We agree to complete a parent’s/guardian’s letter to the applicant’s host.
• We agree that the applicant may travel to the host site and participate fully in the YouthStay program.
• We agree to provide proof of a physical exam within the last year
• We agree to provide a letter of good health from an MD or NP within 3 weeks of the departure date
• We agree to withdraw your child(ren) from participation in the program if your child is showing Covid or flu-like signs/symptoms within 3 days of departure date.
• We agree that this agreement shall be governed and construed in accordance with the laws of the Commonwealth of Massachusetts.