EmailMe Form - Interest Request Form

Child’s Name
First Last
Today's Date
MM / DD / YYYY
Boy
Girl
Age
Date of Birth
MM / DD / YYYY
Parent(s) / Guardian(s)
First Last
Are you bilingual?
Yes
No
What language do you speak at home?
Contact Phone Number
### - ### - ####
Contact Email Address
Physical Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
School Information
Please tell us more about your child's schooling.
Type of School?
Public
Private / Charter
Homeschooled?
Yes
No
School child is currently enrolled at
School Grade
School Starting Time
HH : MM AM/PM
Ending Time
HH : MM AM/PM
More Information About Your Child...
This section of the form helps understand more about your child.
Please describe your child so that we may better understand who he or she is.
Please rate your child in the following areas:
Select 1 - 5 (5 being the highest in the specific character).
Social

1

2

3

4

5
Physically active

1

2

3

4

5
Academic

1

2

3

4

5
Outgoing

1

2

3

4

5
Team Player

1

2

3

4

5
Interaction with Animals

1

2

3

4

5
Mechanical

1

2

3

4

5
Authority (does well with)

1

2

3

4

5
Responsible

1

2

3

4

5
Chores

1

2

3

4

5
Honesty

1

2

3

4

5
Completion of task

1

2

3

4

5
Detailed

1

2

3

4

5
Attentive

1

2

3

4

5
Musician

1

2

3

4

5
Helps others

1

2

3

4

5
Creative

1

2

3

4

5
Happy

1

2

3

4

5
Angry

1

2

3

4

5
Self esteem

1

2

3

4

5
Please describe your child’s family environment and interaction.
Please list siblings:

Gender Age Lives at Home?

Sibling 1

Sibling 2

Sibling 3

Sibling 4
If parents are divorced/separated what are the living arrangements for the applying child?
In your own words please describe why you believe CVYR would be of service for your child?
Any other comments or information that would better help us understand your child’s situation?

Programs CVYR offers: Please check mark the area(s) that your child may be interested in.

	Check if Yes
Crafting (handcrafts, woodworking)
Equine (horses)
Horticulture (plants)
Livestock (small animals)
Music (guitar, ukulele)
Nature (fishing, insects, reptiles, outdoor survival)

How did you hear about Crown Valley Youth Ranch?
If you were referred, please provide the contact person’s name

EMF Contact Form

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	Gender	Age	Lives at Home?
Sibling 1
Sibling 2
Sibling 3
Sibling 4

School Information

More Information About Your Child...

Please rate your child in the following areas: