Interest Form - Down Home Ranch

Thank for letting us know about your interest in the Ranch.

- Step 1 of 5

Contact Information

This is the person who is filling out the interest form.

Contact Name *

First

Last

Contact Email *

Layout

Contact Phone Number *

Cell Phone

Type of Number - Contact Phone Number *

Cell Phone, text
Cell Phone, no text
Home/Office

Potential Rancher's Information

Potential Rancher *

First

Last

City and State where Potential DHR Rancher Currently Lives *

Current City and State of the Potential Rancher

Layout

Gender *

Gender

Date of Birth (mm/dd/yyyy) *

Date of Birth (mm/dd/yyyy)

Current Chronological Age *

Current Age

What Program(s) are of Interest? *

Ranch Camp (Summer Camp, Weekend Camp, Fall Camp, Day Camp)
Day Program
Respite
Residential (ICF, HCS, Private Pay)

Select all that apply - We will get the potential Rancher added to each interest list selected.

Once this form is submitted, you will get an email for each program selected. Visit the following sites to learn more about each program. Each link opens in a new window:

Ranch Camp - (Summer Camp, Weekend Camp, Fall Camp, Day Camp)
Day Program
Respite
Residential - (ICF, HCS, Private Pay Group Living, Private Pay Supported Independent Living)

Responsible Party #1

Be sure to keep the Ranch informed of changes in address, phone numbers, emails and other contact info.

Responsible Party #1 - Name *

First

Last

Responsible Party #1 - Relationship *

Legal Guardian
Legal Authorized Representative (LAR)
Mother
Father
Sibling
Family Member
Case Manager
Other

Select all relationships that apply

Responsible Party #1 - Relationship - Other *

Responsible Party #1 - Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Responsible Party #1 - E-mail *

Layout

Responsible Party #1 - Primary Phone # *

Cell Phone

Responsible Party #1 - Secondary Phone #

Alternate Phone

Type of Number - Responsible Party #1 - Primary Phone *

Cell Phone, text
Cell Phone, no text
Home/Office

Type of Number - Responsible Party #1 - Secondary Phone

Cell Phone, text
Cell Phone, no text
Home/Office

Is there a Second Responsible Party?

Responsible Party #2

Please note that it is your responsibility to keep Down Home Ranch informed of changes in address, phone numbers, emails and other contact info.

Responsible Party #2 - Name

First

Last

Responsible Party #2 - Relationship

Legal Guardian
Legal Authorized Representative (LAR)
Mother
Father
Sibling
Family Member
Case Manager
Other

Select all relationships that apply

Responsible Party #2 - Relationship - Other

Responsible Party #2 - Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Enter mailing address

Responsible Party #2 - E-mail

Layout

Responsible Party #2 - Primary Phone #

Cell Phone

Responsible Party #2 - Secondary Phone # *

Alternate Phone

Type of Number - Responsible Party #2 - Primary Phone

Cell Phone, text
Cell Phone, no text
Home/Office

Type of Number - Responsible Party #2 - Secondary Phone

Cell Phone, text
Cell Phone, no text
Home/Office

What residential funding does the potential Rancher currently receive? *

I pay privately at a location that is not my family's home
Medicaid - Intermediate Care Facility (ICF/IID)
Medicaid - Home and Community Based Services (HCS)
None

Select only one

What residential option(s) are of interest at the Ranch? *

Private Pay - Supported Independent Living
Private Pay - Private Pay Group Living
Medicaid - Intermediate Care Facility
Medicaid - Home and Community Based Services

Select all that apply

Update to an interest form already on file? *

Yes
No, this is a brand new interest form.

What funding source will be used for residency? *

Trust (Assets Set Aside)
Medicaid (ICF, HCS)
Private Pay (Cash, SSI, SSDI, Annuity, etc.)
Other

Select all that apply

Residential Interest - Other funding source *

Describe the potential Rancher. *

Are there any special needs that should be shared, such as hygiene, medical or behavioral? *

What are the potential Rancher's interests, and how would these make them a good fit for Down Home Ranch? *

Have they attended Down Home Ranch Camp, Day Program or another Ranch event? If so, when? *

Are there other things to be considered regarding the potential Rancher's interest in residential services at Down Home Ranch? *

Anything else you would like us to know?

Keep in Contact With The Ranch

How did you find out about Down Home Ranch? (Google, Facebook, Transition Fair, Child's School, DHR Volunteer, etc) *

We would love to provide you with more information on Down Home Ranch. By checking the boxes below, you grant DHR permission to use your personal/business information to further contact you regarding opportunities at the Ranch. *

Email List
Mailing List
DHR Tour Information
Respite Services
Camp Services
Residential Services
Day Program

Disclosure *

Yes, I understand

At the time of submitting your interest, our program may not having any openings.

Please be sure to read the DHR Privacy Practices to better understand how your personal information, submitted through this page, will be used.

All other factors being equal, a potential Rancher who has shown interest longer may not be offered programing before those who have been on the list a shorter time.

From time to time, we will ask for interest forms to be updated. If we do not received an updated form, a phone call or email within 30 days of a requested update; it will be assumed you are no longer interested in programing at Down Home Ranch.

Submission Date and Time *

Date

Time

Phone