Homestead Application Form | Hope Lives Youth Ranch

Homestead Application

Student Name

Date of Birth

Age

Gender

Phone Number

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

Home Phone

Cell Phone

Work Phone

Preferred method of contact:

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.

Check the following statements to acknowledge:

The recommended donation to cover your student's session costs is $25 for one 7-week round.