Mountain Meadow Youth Ranch
Enrollment Application*

Applicant __________________________________________________________
                       (Last)                                                 (First)                                                    (Middle) 

Address ___________________________________________________________
                      (Street)                                           (City)                                    (State)                        (Zip)

Telephone (___) _______________ SS # _______________ DOB _____________

Date of Arrival__________ Transport plan_________________________________

Was applicant adopted? Yes _____ No_____ If so, at what age? _______________

Are parents divorced? Yes_____ No______ If so, who is the legal custodian of 
the applicant? _______________________________________________________

Applicant’s Birthplace _________________________ Ht ______ Wt ____________

Eye color________ Hair color_________ 

Who referred you to us? _______________________________________________
                                                                                        (Name)                             (Title)
Address __________________________________ Telephone ________________

IN CASE OF EMERGENCY NOTIFY:

 Name              Relationship                              Address                      Phone home/work
____________________________________________________________________

____________________________________________________________________

Financial Sponsor _________________________ (___) _______________________
                                                         (Name)                                                    (Telephone)
Address _____________________________________________________________
                   (Street)                                       (City)                                          (State)                                (Zip)

Parent/Guardian’s Name __________________________ Date _________________

Signature ____________________________________________________________

(P1) 1

PARENT INFORMATION

Father                                                          Mother

_________________________________________________     _________________________________________________
Name   (First)   (Middle)     (Last)                                         Name   (First)     (Middle)     (Last)

_________________________________________________     _________________________________________________
Home Address    (Street)                                                           Home Address   (Street)

_________________________________________________     _________________________________________________
(City)                 (State)     (Zip)                                                     (City)                 (State)    (Zip)

_________________________________________________     _________________________________________________
Social Security Number                                                                Social Security Number

_________________________________________________     _________________________________________________
Business Address    (Street)                                                          Business Address   (Street)

_________________________________________________     _________________________________________________
(City)                 (State)     (Zip)                                                     (City)                  (State)   (Zip)

_________________________________________________     _________________________________________________
Current Occupation & Title                                                            Current Occupation & Title

_________________________________________________     _________________________________________________
Telephone (Home)             (Business)                                          Telephone (Home)              (Business)

Stepmother                                                  Stepfather

_________________________________________________     _________________________________________________
Name   (First)   (Middle)     (Last)                                          Name   (First)     (Middle)     (Last)

_________________________________________________     _________________________________________________
Home Address    (Street)                                                          Home Address   (Street)

_________________________________________________     _________________________________________________
(City)                 (State)     (Zip)                                               (City)                 (State)     (Zip)

_________________________________________________     _________________________________________________
Social Security Number                                                           Social Security Number

_________________________________________________     _________________________________________________
Business Address    (Street)                                                      Business Address   (Street)

_________________________________________________     _________________________________________________
(City)                 (State)     (Zip)                                            (City)                  (State)    (Zip)

_________________________________________________     _________________________________________________
Current Occupation & Title                                                       Current Occupation & Title

_________________________________________________     _________________________________________________
Telephone (Home)             (Business)                                      Telephone (Home)              (Business)

(P1) 2

FAMILY INFORMATION

List applicant’s siblings and step or half-siblings in chronological order.  Please note if any siblings are deceased.

            Name                        Sex        Age              Current Residence                Biological/Adopted

___________________   _____   _____   ________________________  __________________

___________________   _____   _____   ________________________  __________________

___________________   _____   _____   ________________________  __________________

___________________   _____   _____   ________________________  __________________

Please list any additional siblings on a separate sheet of paper.

If the applicant is on probation, please provide Probation Officer’s name, address and telephone number.

___________________________________________________________ (____)______________
(Name)                            (Address)                        (State)                    (Zip)                         (Telephone)

Reason for Probation and Dates ____________________________________________________

_______________________________________________________________________________

The following questions are designed to assist us in working most effectively with your family.  Please take a few moments to complete them in their entirety.  Continue your answers on additional paper if necessary.

List the positive qualities, interests and accomplishments of applicant:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

What goals and ambitions has the applicant expressed for his/her life?

__________________________________________________________________________________

__________________________________________________________________________________

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What are your goals for the applicant’s experience with Mountain Meadow Youth Ranch?

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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(P1) 3

Has applicant experienced any traumatic events or major changes in his/her life?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

What do you identify as the applicant’s emotional issues?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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What parental/family issues have affected the applicant?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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Can you identify any patterns of behavior common to both the applicant and any family members?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

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Describe your relationship with your child. ( Both parents if available.) What are the problem areas in your relationship?

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

(P1) 4

APPLICANT BACKGROUND

Has the applicant ever experienced or exhibited any of the following?  If yes, please describe.

Bulimia /Anorexia.     Yes ______ No ______
__________________________________________________________________________________
__________________________________________________________________________________
Fire setting.    Yes ______ No ______
__________________________________________________________________________________
__________________________________________________________________________________
Drug/alcohol/tobacco use.     Yes ______ No _______
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Suicide discussion or attempt.     Yes ______ No ______ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Runaway.     Yes ______ No ______ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Violent behavior.     Yes ______ No ______ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Self abuse.     Yes ______ No ______ 
__________________________________________________________________________________
__________________________________________________________________________________
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Sexual activity.     Yes ______ No ______ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Physical or sexual abuse/rape or witnessed any.     Yes ______ No ______  
__________________________________________________________________________________
__________________________________________________________________________________
Computer/Internet abuse.   Yes _____ No _____
__________________________________________________________________________________
__________________________________________________________________________________
(P1) 5
                                      
ACADEMIC INFORMATION

Academic information is needed for residential placement.  Please include copies of all school transcripts and relevant educational records. 

   School Attended                          School Address                 Dates Attended       Grades Completed

______________________  _____________________  ________________  _________________
______________________  _____________________  ________________  _________________
______________________  _____________________  ________________  _________________
Please list any additional schools on a separate sheet of paper.

Has the applicant ever experienced any of the following?  If yes, please describe.

Been held back a grade?   Yes _____   No _____ 
__________________________________________________________________________________
__________________________________________________________________________________

Been expelled or withdrawn from school?   Yes _____ No _____
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Been the victim or perpetrator of harassment, bullying or violence in a school setting? 
  Yes _____ No _____ 
__________________________________________________________________________________
__________________________________________________________________________________

Had difficulty with a particular teacher?   Yes _____ No _____
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Had a pattern of unexcused tardiness or absences?   Yes _____ No _____ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Had teacher or educator express concern about learning abilities and/or academic performance?  
 Yes _____   No _____ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(P1) 6

Received tutoring or supplemental academic assistance? Yes _____ No _____ 
__________________________________________________________________________________
__________________________________________________________________________________
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Been placed in a special education program?   Yes _____ No _____ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Been placed in accelerated learning or advanced classes?  Yes _____ No _____ 
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Please complete the following questions in their entirety.  Feel free to continue your answers on additional paper.

What are the applicant’s academic strengths and weaknesses?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you have any reservation about placing your child in public school?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
List the applicant’s extracurricular activities and sports.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Other comments or concerns?
__________________________________________________________________________________
__________________________________________________________________________________
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* Application for enrollment at Mountain Meadow Youth Ranch 
(P1) 7