Ben's Ranch Foundation Program Application

Program Application

Thank you for your interest in one of our programs 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
Preferred Name
Age*
Date of Birth*

MonthDayYear
Date
Grade Level*
MaleFemale
HispanicNon-Hispanic
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
County*
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?*
If you were referred to us, please share the reason and who we can thank for the referral:*
If not applicable, enter N/A.
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 teen has missed*
YesNo
If yes, please explain.*
If answer to previous question was no, enter N/A.
YesNo
Psychosocial Information
YesNo
If yes, please explain:*
If answer to previous question was no, enter N/A.
YesNo
If yes, please explain:
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:*
YesNo
If yes, please comment on current emotional/mental stability:*
If answer to previous question was no, enter N/A.
Health Information
Are there any allergies we should be aware of?*
YesNo
YesNo
If yes, please explain:*
If answer to previous question was no, enter N/A.
Drug & Alcohol History
TobaccoOpiates (i.e. Oxycontin, Heroin)Abuse prescription pillsAlcoholCocaineMethamphetamineMarijuanaHallucinogensOther
Please explain any checked items: *
If answer to previous question was no, enter N/A.
Additional Information
If yes, please list the job description, length of employment and job responsibilities.*
If answer to previous question was no, enter N/A.
YesNo
How do you feel your 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 your 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 your teen willing to travel one-way from the teen’s place of residence? (This information determines our host search).*
Small Group ProgramInternshipsBootcampAll of the aboveI'm not sure, please tell me more.
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...*

Rows	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 teen's life... *

Rows	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... *

Rows	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:
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteTwo or more races
Should be Empty:

Program Application

Instructions