Interest Request Form
Dear Guardian, 

We look forward to helping the child interested in our program and understanding them to the full. 
Therefore, to best help us understand who they are, their struggles, and how we can help, please be as detailed as possible. We will use these details to formulate a plan to encourage them to grow emotionally, mentally, spiritually, in character, and in life skills. We also take this into consideration when pairing them with a mentor.  We encourage you to fill out this form with these things in mind:

   - Be HONEST (the good, bad, AND the ugly.)
   - Fill this form out with another individual who knows your child. (Second parent, grandparent, teacher, etc.)
   - Talk to and involve your child when filling out the "Tell Us About Your Child" section.
   - If there is anything important that we need to know about your child other than what has been asked, please let us know in the very last question.
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Email *
Child's Name (first and last) *
Parent(s) / Guardians(s) Name (first and last) *
Contact Phone Number *
Contact Email Address *
Physical Address *
School Child is enrolled in *
Grade & Age *
Child's Date of Birth *
MM
/
DD
/
YYYY
Gender *
Relation *
How did you hear about Redemption Youth Ranch?
If you were referred, please provide the contact person's name
Please describe your child so that we may better understand who he or she is. *
Please detail some background about your child in regards to their current situation to help us understand how we can help. *
Please rate your child in the below areas 1-5 (5 being the often or most, 1 being rarely or minimally) *
1
2
3
4
5
Social Interaction
Creative
Outgoing
Physically Active
Interaction with Animals
Attentive
Academic
Mechanical
Musician
Contentment
Angry
Honesty
Helps Others
Happy
Self-Esteem
Depression
Anxiety
Peer Presure
Team Player
Authority
Responsible
Chores
Completion of Task
Detailed
Motivation
Hard Working
Intimidated by Others
Please check area(s) that your child may be interested in. *
Required
In your own words please describe why you believe RYR would be of service for your child? *
What is your family's or child's religious background? *
Please describe your child's family environment and interaction. *
Please list siblings living at home: Gender & Age *
If parents are divorced/ separated what are the living arrangements for the applying child?
Any other comments or information that would better help us understand your child's situation? *
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