Homestead Application Student Name Date of Birth Age Gender Phone Number Email School Therapist/Counselor Any triggers we need to be aware of Please list any health issues we need to know about: Parent/Guardian Name Relationship to Student Email Home Phone Cell Phone Work Phone Preferred method of contact: select text home phone cell phone work phone email Address City State Zip Code Tell us a little more about your student: How are you hoping Hope Lives Youth Ranch will help your student? Sessions are held once a week in three 7-week rounds from 4-6 PM. Please select the preferred round. Select Round 1 Round 2 Round 3 Check the following statements to acknowledge: The recommended donation to cover your student's session costs is $25 for one 7-week round. submit application