Youth Application – Lakota Youthstay

1Read Before Applying

2Applicant Information

3Parent/Guardian Information

4Personal Background

5Health Information

6References

7Behavior Covenant

8Signature

Read before you start application

ELIGIBILITY REQUIREMENTS:

reside on the Pine Ridge Reservation;
are an enrolled member of the Oglala Sioux tribe;
are 10 – 15 years old at the time of the 2024 trip;
are physically and mentally healthy;
be fully vaccinated and boosted;
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, single Moms, couples or retirees who have been carefully reviewed prior to selection. There is no cost for Lakota participants or their families other than minor incidentals including transportation to/from the Denver airport, snacks and an occasional meal out.

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 with 3 weeks of departure, will be required of all final YouthStay participants.

The Lakota YouthStay week is July 2 – 11, 2024.

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.

A full medical check-up within the last year and proof of vaccination is required prior to final acceptance in the program

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.

Full Legal Name

First Middle Last

Name You Prefer to be Called:

Gender

Male

Female

Date of Birth

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

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

Parent/Legal Guardian Email

Enter Email Confirm Email

Please indicate the best way to communicate with Parent/Legal Guardian

Text

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

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.

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

School Address
Street Address City State ZIP Code

Reference #1 Email

Reference #1 - Best phone number to reach, if needed

Reference #2 Name
First Last

How long has s/he known you?

Address
Street Address City State ZIP Code

Reference #2 Email

Reference #2 - Best phone number to reach if needed

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:

You must be fully vaccinated and boosted as per CDC recommendations for your age group and submit proof of this with your application

If you show Covid-related signs/symptoms immediately prior to or during the YouthStay program, you will be asked to test for Covid. If the test is positive, you will be required to quarantine for the CDC recommended # of days before being allowed to participate in the program.

Costs associated with the YouthStay visit including airfare, meals provided by hosts during the stay from arrival to departure and the cost of all group activities are covered by the program. We do, however, welcome and greatly appreciate monetary contributions in any amount to help defray the costs of airfare and program activities.

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. Transportation to/from the Denver airport is the sole responsibility of the youth's family.

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 for use.

You agree to attend and participate in a minimum of 1 pre-trip YouthStay get-togethers as well as the post-trip get-togethers. Youth that do not attend a minimum of 1 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.

Applicant Email

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

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

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