Application for Respite with Jessica Gray

Applicant Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email Address(Required)

Occupation(Required)

Marital Status(Required)

Married

Single

Spouse's Name(Required)

First Last

Spouse's Phone(Required)

Spouse's Email(Required)

Program Participation

Jumpstart Completion (Month/Year)(Required)

Please select all that apply.(Required)

My family has participated in a Parent Coaching Intensive at King’s Ranch.

My family has participated in a Family Attachment Intensive.

We are currently implementing Unplowed Ground therapeutic parenting techniques in our home.

My child is familiar with “stations”.

My child is familiar with saying “excuse me” to get my attention.

Please list the dates associated with your selection(s).(Required)

Child Information

Child's Full Name(Required)

First Last

Birthdate(Required)

Height(Required)

Weight (lbs)(Required)

Please enter a number greater than or equal to 0.

Is the child's address the same as yours?(Required)

Yes

No

Child's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

My child is..(Required)

biological

adopted

in the foster care system

Child Behavior

Please answer the following questions about your child.

Please select all that apply.(Required)

My child has a history of running away.

My child has a history of violent outbursts.

My child has a history of hurting animals.

My child has a history of making false allegations of abuse.

My child has expressed suicidal thoughts or ideations.

None of the above apply to my child.

Please explain and elaborate on any of the above that you selected as applicable to your child.(Required)

Additional Information

Any additional details you can provide will help us as we prepare for respite as it will help us better understand your family’s needs.

Please use the space below to share any additional information about your child (strengths, challenges, examples of behaviors, etc…). Please include any additional information that you think we should be aware of.(Required)

Please share any special information (special needs, dietary restrictions, etc…) specific to your child.(Required)

Emergency Contact

Name(Required)

First Last

Relationship to Child(Required)

Phone(Required)

Email(Required)

Signature(Required)

CAPTCHA

Thank you for completing this application. Your information will help us provide the best possible respite care for your family. If you have any questions, please contact our support staff by emailing jessica@kingsranch.net

Respite Services Application (Jessica Gray)

Applicant Information

Program Participation

Child Information

Child Behavior

Additional Information

Emergency Contact

Thank you for completing this application. Your information will help us provide the best possible respite care for your family. If you have any questions, please contact our support staff by emailing jessica@kingsranch.net

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Application for Respite with Jessica Gray

Respite Services Application (Jessica Gray)

Applicant Information

Program Participation

Child Information

Child Behavior

Additional Information

Emergency Contact

Thank you for completing this application. Your information will help us provide the best possible respite care for your family. If you have any questions, please contact our support staff by emailing jessica@kingsranch.net

PoliciesRefund PolicyLog In

Policies
Refund Policy
Log In