New Rancher Intake
Rancher Information
Rancher Name
*
First Name
Last Name
Nickname
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Non-Binary
Height
*
Weight
*
Hair Color
*
Eye Color
*
Primary Disability
*
Reasons for Participating
*
Physical Activity
Motor Development
Responsibility
Skill Development
Group Interaction
Creativity/Self Expression
Entertainment
Socialization/Friends
Self-Esteem/Confidence
Fun
Other
Ethnicity
*
Hispanic/Latino
American Indian or Alaska Native
Asian
Black or African America
Native Hawaiian or Other Pacific Islander
Caucasian
Decline to State
Other
Rancher Photo ID (government or school issued)
*
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Golden Heart Ranch staffs 1 staff per 3 Ranchers. Any Rancher requiring additional support for using the restroom, elopement/won't stay with the group, aggressive behaviors, or requiring constant supervision for seizures is required to bring their own 1:1 background checked support person. GHR does NOT supply 1:1 support. Will your Rancher be attending with 1:1 support?
*
Yes
No
How did you hear about Golden Heart Ranch?
*
Is your Rancher interested in Camp Coyote Ridge Overnight
*
Yes
No
Family Information
Parent/Guardian Name
*
First Name
Last Name
Relation to Rancher
*
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email
*
example@example.com
Add Another Parent/Guardian?
*
Yes
No
Parent/Guardian Name #2
First Name
Last Name
Relation to Rancher
Parent/Guardian #2 Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian #2 Email
example@example.com
Add Additional Emergency Contact?
*
Yes
No
Additional Emergency Contact
*
First Name
Last Name
Additional Emergency Contact Relationship
*
Additional Emergency Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Information
Does Rancher have any allergies? (food, environment, medicine, etc..)
*
Yes
No
Allergen
Reaction
Response to Take
Add another Allergen?
Yes
No
Allergen
Reaction
Response to Take
Add another Allergen?
Yes
No
Allergen
Reaction
Response to Take
Add another Allergen?
Yes
No
Allergen
Reaction
Response to Take
Does Rancher have any dietary restrictions
*
Yes
No
Please List Restrictions
Is Rancher subject to seizures?
*
Yes
No
Date of Last Seizure
-
Month
-
Day
Year
Date
Type and Frequency of Seizure
Please complete the
Epilepsy Foundation Seizure Response Form
and upload.
Seizure Response Form
*
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If Rancher has Down syndrome have they been tested for Atlanto-Axial instability?
*
Yes
No
Not Applicable
Results were:
Positive (instability)
Negative (no instability)
Daily Living Skills
Eating
*
Eats Independently
Type option 2
Needs 1:1 Assistance/Fed
Is at high risk of chocking
Other
Mobility
*
Walks Independently
Needs support to walk
Uses Manual Wheelchair
Uses Motorized Wheelchair
Uses other mobility device
Other
Communication
*
Verbal - speaks clearly
Verbal - may be difficult to understand
Gestures/Points
Uses Communication DeviceAAC/iPad
Speller
Sign Language
Other
Dressing
*
Dresses Independently
Needs Verbal Prompting
Requires 1:1 Assistance
Other
Auditory/Visual
*
Wears Glasses
Wears hearing aids/device
Not Applicable
Other
Restroom
*
Toilets Independently
Needs to be Monitored
Needs 1:1 Assistance
Other
Changing Pull Up
*
Not Applicable
Changes Independently
Needs to be Monitored
Needs 1:1 Assistance
Other
Swimming
*
Swims Independently in DEEP end
Swims independently in SHALLOW end
Swims with Special Gear
Cannot Swim
Other
Social
Social Interaction
*
Initiates Social Interaction
Socializes with Verbal Prompting
Avoids Social Interactions
Other
Is Most Successful in
*
Large Groups
Small Groups
Other
Engages
*
From a Distance
Directly with Others
Other
Favorite Quiet Activites
Favorite Active Activities
Ranchers strengths and talents at home, at school, and in the community.
Areas that your Ranch needs extra help?
How does your Rancher best learn?
What are your Ranchers social goals?
Behaviors
Sensory: Aversion to textures, loud noises? etc..
*
Behaviors
*
Short Attention Span
Oppositino/Defiant
Verbal Outbursts
Physical Aggression Towards Self
Physical Aggression Towards Others
Easily Distracted
Tendency to Run or Wander Off
Tantrums/Meltdowns
Hyoeractivity
None of the Above
Other
Does your Rancher respond to specific behavior management techniques used at home, school, or work?
*
Yes
No
Please Share these Techniques
How does your Rancher handle frustration? Ho do or don't they communicate stress or frustration?
*
Does your Rancher have any unusual fears or concerns?
*
Yes
No
Please elaborate on these fears
Safety Concerns
*
Crossing Streets
Riding in Vehicles
Elopment
None of the Aboce
Other
Camp Coyote Ridge
Sleeping
*
Sleeps Through the Night
Afraid of the Dark
Wears diaper/pull up at Night
Sleepwalking/Wandering at Night
Able to Sleep on Top Bunk
Has Nightmares
Soils the Bed
None of the Above
Other
Please Explain how we can best Manage these Habits
*
Favorite Foods
*
Food Aversions
*
How can we best support your Rancher with their sensitive personal habits while at camp? (please note Ranchers must be independent in restroom in order to participate in CCR)
*
Brushing Teeth
*
Brushes Independently
Needs to be Monitored
Needs Assisance
Other
Showering
*
Showers Independently
Needs to be Monitored
Needs Assistance
Other
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