Your Contact Information

First Name

Last Name

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country

Birthday

T-Shirt Size

Email *

Phone *

How would you prefer to be contacted by the Ranch? *

All are good

Physical Mail

Email

Phone Call

Text

What is the best time to reach you? *

Morning

Afternooon

Evening

Relationship to Potential Rancher *

Potential Rancher's Information

Potential Rancher First and Last Name *

City and State where Potential DHR Rancher Currently Lives *

Gender *

Potential Rancher Date of Birth *

Potential Rancher Chronological Age *

What program(s) are of interest? *

Ranch Camp (Summer, Weekend, Fall, Day)

Respite

Residential (ICF, HCS, Private Pay, Independent Living Experience)

Day Program (Hobbies and Interest Development)

Vocational (Horticulture, Animal Husbandry, Camp Program Staff)

Has the potential Rancher ever attended camp at Down Home Ranch? *

Funding

What residential funding does the potential Rancher currently receive? *

Update to an interest form already on file? *

What residential option(s) are of interest at the Ranch? *

Private Pay – Supported Independent Living (long term)

Private Pay – Private Pay Group Living (long term)

Private Pay – Independent Living Experience (short term)

Texas Medicaid – Intermediate Care Facility (long term)

Texas Medicaid – Home and Community Based Services (long term)

What funding source will be used for residency? *

Private Pay - Trust (Assets Set Aside)

Private Pay - Multiple Sources (Cash, Family to Help, SSI, SSDI, etc.)

Medicaid (ICF, HCS)

When are you hoping to begin residential services at Down Home Ranch? *

About the Potential Rancher

Describe the potential Rancher *

Are there any special needs that should be shared, such as hygiene, medical or behavioral? *

What are the potential Rancher's interests, and how would these make them a good fit for Down Home Ranch? *

Have they attended Down Home Ranch Camp, Day Program or another Ranch event? If so, what event and when? *

Are there other things to be considered regarding the potential Rancher's interest in residential services at Down Home Ranch? *

Anything else you would like us to know?

Keep in Contact With The Ranch

How did you find out about Down Home Ranch? (Google, Facebook, Transition Fair, Child's School, DHR Volunteer, etc) *

We would love to provide you with more information on Down Home Ranch. By checking the boxes below, you grant DHR permission to use your personal/business information to further contact you regarding opportunities at the Ranch. *

Email List

Mailing List

Text Messages

DHR Tour Information

Camp Services

Respite Services

Day Program

Residential Services

Disclosure

Please be sure to read the DHR Privacy Practices (link at the bottom of each webpage) to better understand how your personal information will be used submitted through this page.

All other factors being equal, a potential Rancher who has shown interest longer may not be offered programing before those who have been on the list a shorter time.

From time to time, we will ask for interest forms to be updated. If we do not received an updated form, a phone call or email within 30 days of a requested update; it will be assumed you are no longer interested in programing at Down Home Ranch.

Agreed to Disclosure *

Date Submitted *

Data Privacy & Consent

I'd like to recieve SMS/MMS from Down Home Ranch.