RESIDENT APPLICATION
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GENERAL INFORMATION

 
Today's Date:

 
First and last name of person filling out application:

 
What is your relationship to the applicant?


 
Please provide your email address and phone number.

 
How did you hear about Still Creek Ranch?

 
Why you are seeking placement for the student?

 
Is the student aware of his/her possibility of being placed at Still Creek Ranch?

     
 
APPLICANT INFORMATION

 
Student's Name: (First, Middle, Last)

 
Age:

 
Birthdate:

 
Grade:

 
Height:

 
Weight:

 
Who does the student currently live with? (Name and relationship to student)

 
Current address of the student:

 
Who has legal custody of student?

 
Is applicant adopted?

     
 
If yes, at what age and by who?

 
Please describe student’s current relationship with biological mother.

 
Please describe student’s current relationship with biological father:

 
Are the student's biological parents divorced?

     
 
Please list student’s siblings (biological and adoptive) and their ages.

 
Describe the student's relationship with siblings.
ex) Gets along well with sisters but not brother, relationship with siblings is strained, etc.

 
What are the student's strengths?

 
What are the student's weaknesses?

 
What are the student’s personal interests and/or hobbies? (please list)

 
Has the student ever been convicted of a crime? If yes, please explain.

 
Is the student currently on probation or has a charge pending? If yes, please explain.

 
Has student ever been in (or is currently in) a facility like Still Creek Ranch?

     
 
If yes, where and why was child removed/dismissed?

 
Please use this space to provide any additional comments/details about the student that might aid us in the admission review process.

 
FAMILY INFORMATION

 
Religious preference (if any):

 
Please give a brief description of the applicant’s religious background & experience, if any.  Ex.) has been baptized, has been raised muslim, has accepted Jesus Christ as savior, etc.

 
Briefly describe the applicant’s overall family situation, highlighting both positive and negative aspects of the child’s family environment.

 
Briefly describe the applicant's disruptive or acting out behavior:

 
When did these behaviors begin?

 
Please list any past or present contributing factors to applicant’s negative behavior:

 
Describe any traumatic events in the student's life:

 
Has the applicant ever been sexually abused? If yes, please give brief explanation.

 
Has the applicant ever been physically abused? If yes, please briefly explain.

 
Describe the student's relationship with peers outside of school:

 
Describe the student's social interaction style. Ex.) normal, isolates self, shy, outgoing, dominates conversation, associates by acting out for attention, etc.

 
What methods of discipline are currently used in the home?

 
Has the student ever run away? If yes, please explain.

 
MEDICAL INFORMATION

 
Does the student currently have health insurance coverage? Ex.) Medicaid, Blue Cross Blue Shield, Scott & White, etc.

 
Does the student currently have a doctor? If so, please provide the doctor's name and contact information.

 
When was the last time the student was seen by a doctor?

 
Does the student currently have a dentist? If so, please provide the dentist's name and contact information.

 
When was the last time the student was seen by a dentist?

 
Has the student ever been prescribed any medication? If so, please list any medication(s) the student has taken or is currently taking and how long they have been taking it.

 
Is the student currently in any type of counseling or therapy? If yes, please explain.

 
Does the student have any allergies? Ex.) Bees, peanuts, medicines, animals, etc.

 
Does the student wet the bed?

     
 
Is the student sexually active?

     
 
Has the applicant ever tested positive for a sexually transmitted disease?

     
 
Has the student ever had a positive pregnancy test?

     
 
Please select any and all behaviors the student has exhibited in the past:


 
EDUCATION INFORMATION

 
Is the applicant currently enrolled in school? If yes, where and for how long?

 
Name and addresses of all schools the applicant has attended in the last three years:

 
Has the student ever been held back in school? If yes, what grade(s) and why?

 
Has the student ever been tested for learning disabilities? If so, what were the results?

 
Does the applicant have an IEP (Individualized Education Plan) or 504 Plan? If so, what plan are they on and when was it last updated?

 
Describe the students interaction with school authority.

 
Describe the students interaction with peers in school:

 
What is the applicant's favorite subject in school and why?

 
What is the applicant's least favorite subject in school and why?

 
Is there any additional information in regards to the students school/education that would help us in the admission review process?

 
I understand that Still Creek Ranch is a Christian home & boarding school for male & female students ages 10 to 17, which admits children who are between 10-14. I am aware that my child/applicant, if accepted for admission, will be taught and counseled by the principles and doctrines of the Bible. I agree to these terms.

     
 
After submitting this application, please email the following items to apps@stillcreekranch.org.  
1) Most recent report card 
2) 504 Plan

Application complete! You will be contacted within 2 weeks of our office receiving your application.

Please do not forget to email the following items to apps@stillcreekranch.org.  
1) Most recent report card 
2) 504 Plan



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