Ben's Ranch Foundation Program Application

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*
Date of Birth*

MonthDayYear
Date
Grade Level*
Gender*

MaleFemale
Race*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more races
Ethnicity*

HispanicNon-Hispanic
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Teen Phone Number (This information will not be shared with anyone outside of BRF.)

Area CodePhone Number
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 your teens' level of academic achievement:*
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?*

YesNo
If yes, please explain.
Does your teen qualify for free/reduced lunch?

YesNo
Psychosocial Information
Has the teen ever been arrested?*

YesNo
If yes, please explain:
Has the teen been a perpetrator of emotional, physical, or sexual abuse?*

YesNo
If yes, please explain:
Check all the problems/behaviors that currently apply to your teen:*

TraumaLack of motivationPoor self-esteemGriefDefiancePoor decision makingRelationship/friendship problemsInternet/video game addictionSubstance abuseSocial isolationDisruptive at homeSense of entitlementDisruptive at schoolAnger issuesSelf-harming behaviorsMood disturbancesAnxietyOther
Please describer any other current problematic symptoms:*
Has the teen attempted suicide in the last six months?*

YesNo
If yes, please comment on current emotional/mental stability:
Health Information
Are there any allergies we should be aware of?*
Does the teen carry an epipen?*

YesNo
Will the teen need to have any medication and/or supplement with them during their program hours?*

YesNo
If yes, please explain:
Drug & Alcohol History
To your knowledge, has the teen ever used any of the following? Check all that apply:*

TobaccoOpiates (i.e. Oxycontin, Heroin)Abuse prescription pillsAlcoholCocaineMethamphetamineMarijuanaHallucinogensOther
Please explain any checked items:
Additional Information
Has the teen ever been employed?*

YesNo
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*

	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 which program(s) you're interested in for your teen:

Small Group ProgramInternshipsBootcampAll of the aboveI'm not sure, please tell me more.
If inquiring about internship, please check what style of internship would be most preferential:

After SchoolSummerWeekendsAll of the Above
Ideal start date:*

MonthDayYear
Date
Parent/Guardian Survey

This survey is to be completed by the parent or guardian only, NOT by the teen.

Please respond to each question or statement by marking one box per row. In the past 7 days...*

	Never	Rarely	Sometimes	Often	Always
My child felt happy.
My child felt great.
My child felt cheerful.
My child felt joyful.

Please respond to each question or statement by marking one box per row. Thinking about your child's life... *

	Not at all	A little bit	Somewhat	Quite a bit	Very much
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.

Please respond to each question or statement by marking one box per row. In the past 7 days... *

	Never	Almost never	Sometimes	Often	Almost 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