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Leave the Couch 2026 Native Youth Program

Sacred Pipe Resource Center – Leave the Couch 2026 – Native Youth Program

Get registered for this week’s LTC 2026 event! – All event are FREE for indigenous youth and friends ages 10-17 living in the Bismarck-Mandan-Lincoln area. – Parental Permission and REGISTRATION are required. – Limited Transportation is available. – Refreshments and Snacks provided. – Watch for weekly flyers and social media (FB) with updated information. FEATURING DREAMSTARTER Tucker Smith’s Project, “Putting the Eat in Athlete”: Try NEW high-efficient super foods for Optimum Health and Performance!

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SACRED PIPE RESOURCE CENTER – 2026 LEAVE THE COUCH REGISTRATION & WAIVER FORM

**GENERAL INFORMATION**

EVENT NAME: COOKOUT & LAWN GAMES – JUNE 3 / 1-3 PM – SERTOMA PARK SHELTER #10

Event you are registering for to attend.
Participant Name*
Please provide first and last name.
Please enter a number from 10 to 17.
Address*
First
Last

**CAMP INFORMATION** • Parents/Guardians are responsible for transportation to and from the camps (unless otherwise noted). • All participants should dress in appropriate clothing and proper shoes. • Participants are responsible for the safekeeping of any extra belongings (e.g. wallets, phones, etc.) they choose to bring to the event(s). • Lunch, snacks, and water/drinks will be provided for all participants. Please inform the staff prior to the day of the camp if your child has any dietary restrictions. • Inappropriate behavior such as bullying, fighting, disrespecting the staff and/or volunteers, etc., will not be tolerated. SPRC reserves the right to eject any participant engaging in such behaviors.

If there are no Allergy conditions, please write None.
If there are no Medical Conditions, please write None.
If there are no Dietary Restrictions, please write None.
If there is no Other Pertinent Health Information, please write None.

**WAIVER OF LIABILITY AND RELEASE** While the staff of the SPRC Leave the Couch Project strives to maintain a safe and healthy environment for all participants, occasional injuries or illnesses require medical attention. We are asking you to sign the permission form below so that we may provide the best possible care for your son/daughter. We will make every attempt to contact the parent/guardian before seeking treatment. **I have given my son/daughter permission to participate in the SPRC Leave the Couch activities, and I certify that (s)he is in good health has been cleared by a physician and can take part in all physical activities. I am aware of all laws, rules, and safety procedures regarding head concussions. If an injury occurs, I authorize staff members to take all proper action and use the emergency service available at the nearest hospital if necessary. I understand my personal insurance will be used in this case. I give permission for the staff of SPRC Leave the Couch to authorize necessary emergency medical treatment for my child if I am not available to give such consent. I understand that participation in SPRC Leave the Couch event(s) involves risk and dangers. I hereby release, hold harmless, discharge, and agree not to take any legal action against Sacred Pipe Resource Center, its directors, officers, employees, volunteers, agents, sponsors, advertisers, owners/leasers of premises for all liability from my son/daughter’s participation in these activities. **I also understand and agree that Sacred Pipe Resource Center retains the right to use for publicity and advertising, photographs and video taken of the participants during SPRC-sponsored activities.

Please read this section Carefully.
Please check the box if you agree to the Waiver of Liability and Release.*
Date*