Residency Interest

Contact Information

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

Contact Name *

First

Last

Contact Email *

Email

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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

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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 - Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Responsible Party #1 - E-mail *

Email

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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?

Yes
No

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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. *

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

disclosure

ICF/IDD Program Only