ARCHIVED Ben's Ranch Foundation Internship Application (Pre Feb. 2024)

Program Application

Thank you for your interest in an internship for your teen through Ben’s Ranch Foundation, a 501(c)(3) nonprofit organization. Our mission is to create better futures for young people struggling with mental health challenges by connecting them to employment on farms, ranches, stables, and equine therapy facilities.
Instructions

This form is to be filled out by the parent/guardian, NOT the teen.
Intern / Teen Information
Full Name

First NameLast Name
Age
Grade Level
Gender
Race
Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent / Guardian Contact Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address (If different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Information
How are you related to the teen applying?
How did you hear about BRF?
Who referred your teen to BRF?
Why was your teen referred to BRF?
Education Information
Where does your teen attend school?
What grade is your teen in?
(number only)
Describe the level of academic achievement:
What is your teen's GPA?
Does your teen have an IEP?
Is your teen enrolled in a curriculum based on intellectual or emotional disability?
In the last 30 days of scheduled classes, please estimate how many days of school your child has missed
Has your child been suspended, had any detentions, or other school behavior issues? Please explain:
Psychosocial Information
Does any active dispute over custody exist which might affect the teen’s ability to participate? If so, please briefly describe.
Is the teen involved with any CPS/CASA caseworkers? Please list the name, organization, and address:
Has the teen ever been arrested? If yes, please explain:
Has the teen been a victim or perpetrator of emotional, physical, or sexual abuse? If yes, please explain:
Check all the problems/behaviors that currently apply to your teen:

Other
Please describer any other current problematic symptoms:
Has the teen ever had suicidal ideation or attempted suicide? Please explain.
Please list all current and previous psychiatric diagnoses for the teen. Please include year of diagnosis.
Health Information
Please list any allergies and medications used to treat them:
Are any allergies anaphylactic? If so, please list them.
Does the teen carry an epipen?
List all current and recent physicians and mental health professionals providing counseling and medical services to the candidate:
Please list all current medical issues for which the teen is being treated:
List all prescribed medications, doses, and directions:
Will the teen need to have their medication and/or supplement with them during their internship hours?
Has the teen ever had cardiovascular, respiratory, or musculoskeletal issues?
Has your teen ever been hospitalized for any reason? Please explain:
Drug & Alcohol History
To your knowledge, has the teen ever used any of the following? Check all that apply:

Other
Please explain any checked items:
Additional Information
Has the teen ever been employed?
If yes, please list the job description, length of employment and job responsibilities.
How do you feel the teen would react to working in a farm/stable/ranch setting? (Working with and around livestock and/or horses, performing physical labor, working in a barn/stable around dirt).
Would the teen drive to and from the work site, or be driven by family members, etc...?

Availability: Place an X for available dates and times

Rows	Sun	M	T	W	Th	Fri	Sat
Morning
Afternoon
Evening

How far, in minutes, is the individual responsible for transporting the teen willing to travel one-way from the teen’s place of residence? (This information determines our host search).
Check what style of internship would be most preferential:
Ideal start date:

MonthDayYear
Date
Parent/Guardian Survey
This survey is to be completed by the parent or guardian only, NOT by the teen. Choose whichever answer seems to best describe your teen, or what has been most applicable for the past seven days.

PROMIS SF 4a - Positive Effect

Rows	Never	Rarely	Sometimes	Usually	Always
My child felt happy
My child felt great
My child felt cheerful
My child felt joyful

PROMIS SF 4a - Meaning & Purpose

Rows	Never	Rarely	Sometimes	Usually	Always
My child is hopeful about his/her future
My child can reach his/her goals in life
My child thinks his/her life is filled with meaning
My child thinks his/her life has purpose

PROMIS SF 8a - Anxiety (Parent Proxy)

Rows	Never	Rarely	Sometimes	Usually	Always
My child felt nervous
My child felt scared
My child felt worried
My child felt like something awful might happen
My child worried when he/she was at home
My child got scared really easily
My child worried about what could happen to him/her
My child worried when he/she went to bed at night

Please add anything else you feel is important for us to know about the teen:
Should be Empty:

Program Application

Instructions