Student Application Form | Hope Lives Youth Ranch

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Student 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. Please select the preferred round.

Round 1: May 6 - June 21 Round 2: July 1 - August 16 Round 3: August 19 - October 4

Please check all the time slots that will work for your family. A team member will contact you with the final schedule one week before sessions begain.

Monday - 3:30 Monday - 5:30 Tuesday - 3:30 Tuesday - 5:30 Thursday - 3:30 Thursday - 5:30 Friday - 3:30 Friday - 5:30

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. 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.

976 E 2250 North Rd
Monticello, IL 61856

309-339-1641

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Hope Lives Youth Ranch is a registered 501(c)3 located in Central Illinois

Created and Managed by Accuraty Solutions