Student 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 Guardian 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? Check the following statements to acknowledge: To reserve your place on the schedule, please submit your session fee of $140 for mentoring along with your application. Note: You will be redirected to our Donation page to submit your payment after you click the "submit application" button. Please choose the appointment time that will work for you on our sign-ups genius. Be aware that this will be your session time for the entire 7-week round. (An email will follow upon form submission) In order to protect the health of our horses, we have a weight limit of 180 lbs. for riders. Students exceeding this weight limit are more than welcome to participate in the program while we work with the animals from the ground. Submit Application
