1Permission for Medical Care and Release from Liability
2Declaration by Parents/Legal Guardians
  • 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 its agents, the Host Families and the West Medford Community Center as well as its agents from 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, or West Medford Community Center 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 the West Medford Community Center 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.

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