Youth Application – Lakota Youthstay

1 Read Before Applying

2 Applicant Information

3 Parent/Guardian Information

4 Personal Background

5 Health Information

6 References

7 Behavior Covenant

8 Signature

ELIGIBILITY REQUIREMENTS
- reside on Pine Ridge Reservation;
- are an enrolled member of the Oglala Sioux tribe;
- are 10 – 15 years old at the time of the 2020 trip;
- are physically and mentally healthy;
- able to adapt to a different environment for a week;
- are open to having new experiences and exploring new places;
- would like to spend time with native and non-native youth and adults in another part of the country
GENERAL INFORMATION AND INSTRUCTIONS
The Lakota YouthStay Program provides an opportunity for youth people from the Pine Ridge Reservation to stay with hosts in the greater Boston area. Hosts may include families, couples or individuals who have been carefully reviewed prior to selection. There is no cost for Lakota participants or their families other than minor incidentals including snacks and an occasional meal. A full medical check-up within the last year is required prior to final acceptance in the program. In addition, a letter of good health from a physician or NP, dated within 2 weeks of departure, will be required of all final YouthStay participants.
The Lakota YouthStay week is July 14 – July 23, 2020.
Read all directions carefully before completing the application. If you are accepted into the YouthStay program, this application will be sent to the hosts and will serve as your introduction to them.
Each application will be reviewed by the YouthStay staff and members of the Advisory Team. Once initial selections are made, references will be contacted. Once final selections are made, we will contact you and your family to talk with you about the program and answer any questions that you might have.
PRIVACY PROTECTION
Your information will be used only for official YouthStay business. It will not be sold or shared with other third parties unless required by law.
STATEMENT OF CONDUCT FOR WORKING WITH YOUTH
The Lakota YouthStay Program strives to create and maintain a safe and healthy environment for all youth who participate in the program. All volunteers, Advisory Team members and hosts are required to provide high quality care for the youth and to protect them at all times from any physical, sexual or emotional harm.

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Full Legal Name
First Middle Last
Name You Prefer to be Called:
Gender
- Male
- Female
Date of Birth
Date Format: MM slash DD slash YYYY
Place of Birth
City
State
Country
Home Address
Street Address Address Line 2 City State ZIP Code
- My mailing address is different than my home address
Mailing Address
Street Address Address Line 2 City State ZIP Code
Name of School
What grade are you currently in?
Youth's Email
Enter Email Confirm Email
Youth's Home Phone
Youth's Cell Phone

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Full Name of Parent/Legal Guardian
Relationship to You
Address
Street Address Address Line 2 City State ZIP Code
Parent/Legal Guardian's Home Phone
Parent/Legal Guardian's Cell Phone
Full Name of Parent/Legal Guardian
Relationship to You
Address
Street Address Address Line 2 City State ZIP Code
Parent/Legal Guardian's Home Phone
Parent/Legal Guardian's Cell Phone
Please list other family members that live with you and your relationship with them
Name Age Relationship
Name Age Relationship
Name Age Relationship
Name Age Relationship
Name Age Relationship
Name Age Relationship
- Check here if your parents are divorced, separated, or unknown.
  Authorizations must be obtained from all parents/legal guardians and other who have legal rights to decisions affecting the young person's participation in this program.

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Do you have any significant medical/dental/mental health conditions that you would like us to be aware of? If so, please explain fully.
Have you been treated for any medical/mental health conditions in the past two years? If so, please explain fully.
Have you taken any prescribed medications in the past six months? If so, please provide full detail.
Do you have any food allergies/sensitivities?
Please describe your food preferences.
Do you have any dietary restrictions (gluten-free, no dairy, etc.)?
Please note: A full medical check-up within the last year is required prior to final acceptance in the program. In addition, a letter of good health from a physician or NP, dated within 3 weeks of departure, will be required of all final YouthStay participants. I understand my child/grandchild will not be permitted to participate in the YouthStay program unless this information is submitted prior to the departure date.

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Two written references are required and must accompany your Lakota YouthStay application.

Your first reference must be from a current or former teacher familiar with you and your school activities.

Your second reference must be from an adult not related to you who knows you well and can speak to your character and involvement in your community

Reference #1 Name
First Last
How long has s/he known you?
School
Address
Street Address Address Line 2 City State ZIP Code

Reference #1 Email

Reference #1 - Best phone number to reach if needed
Best time to call

: HH

MM

Reference #2 Name
First Last
How long has s/he known you?
Address
Street Address Address Line 2 City State ZIP Code

Reference #2 Email

Reference #2 - Best phone number to reach if needed
Best time to call

: HH

MM

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If you are selected as a YouthStay program participant, you must agree to the following rules and conditions. Violation of any of these rules may result in dismissal from the program and immediate return home at your own expense. Rules and Conditions

Costs associated with the YouthStay visit including ground transportation to and from the airports, airfare, meals provided by hosts during the stay from arrival to departure and the cost of all group activities are covered by the program.

Purchase of minor incidentals such as souvenirs, snacks, meals while traveling to/from Boston, gifts, occasional meal out, etc. are the sole responsibility of the youth participant unless freely offered by the hosts or other YouthStay staff.

You must obey the laws of the country/state/county/city. If found guilty of violating any law, you may be required to return home at your own expense.

You will be under the program’s supervision and the host’s guardianship while participating in the YouthStay program and must abide by the conditions of the household and program.

No smoking, drinking of alcohol or use of illegal drugs is allowed. Medicine prescribed to you by a physician is allowed and must be accompanied by a physician’s note referencing the dosage and schedule fo use.

You agree to attend and participate in a minimum of 3 pre-trip YouthStay get-togethers as well as the post-trip get-together. Youth that do not attend a minimum of 3 pre-trip get-togethers may be disqualified from participating in the program and can re-apply the following year.

You agree to follow travel arrangements established by the YouthStay program with no deviations.

If selected as a YouthStay participant, you agree to communicate by email, phone and/or letter with your hosts prior to the visit. The host’s information will be provided to you prior to your departure for the visit.

You agree to forego use of cell phones during the YouthStay week except during times designated by YouthStay leaders.

You agree to use the buddy system and adhere to YouthStay leader instructions while traveling and participating as a YouthStay participant.

Bullying, lying, stealing or any other serious misbehavior will not be tolerated. Any YouthStay participants engaging in serious misbehavior will receive a verbal warning and counseling regarding appropriate behavior. Any further incidences of serious misbehavior may result in dismissal from the program. Should dismissal from the program become necessary, all travel costs to return home will be the sole responsibility of the youth’s family.
If selected as a participant in the Lakota YouthStay program, I hereby agree to abide by the Rules and Conditions as stated above and will do my best to contribute to a successful YouthStay visit.

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Applicant's Full Legal name
First Middle Last
Applicant's Signature
Date Signed
Date Format: MM slash DD slash YYYY

Parent/Guardian's Name
First Last
Parent/Guardian's Signature
Date Signed
Date Format: MM slash DD slash YYYY

Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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