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:

To reserve your place on the schedule, please submit your session fee of $70 for homestead along with your application. Note: You will be redirected to our Donation page to submit your payment after you click the "submit application" button.

Homestead Application

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