Littlegrass Ranch, Inc. :: Shelter for women, children and their animal family including horses and 4H animals

Client Information

Enter information about yourself here. Please be as thorough as possible.

Last name *

First Name & Middle Initial *

Date of Birth *

Drivers License Number *

Social Security Number *

Gender *

Female

Male

Currently Residing At: *

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

Contact Number *

Safest method and time for us to contact you *

Highest Grade Level Completed *

Marital Status *

Number in family *

How many girls & ages? *

How many boys & ages? *

Please list any medical conditions of either your children or yourself. If none, put "none". *

Spouse Information

Enter information about your spouse/partner here. Please be as thorough as possible.

Name *

First Last

Age *

Social Security # if you do not have it, put "unknown" *

How long were you together? *

Have there been any police reports filed? *

Yes

No

If you answered yes above, please attach a copy of the report.

Report 2

Report 3

Employment and Income

Please check any form of income you receive for all members of the household.

Income *

Employment

SSI/SSD

Alimony

Child Support

Pensions

Food Stamps

Social Security

Unemployment Benefits

Other

Total Monthly Income *

Are you currently employed? *

Yes

No

Describe your employment situation. If you are unemployed, please indicate that you are. *

Are you currently in school? *

Yes

No

Your Previous Addresses:

List all addresses for the past three years.

Address *

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

Address *

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

Address

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

Dependent Children Living with You

Enter complete information for each child

Name of Child 1

First Last

Date of Birth

Do you have legal custody?

Yes

No

Joint Custody

Social Security #

Last grade completed

Name of Child 2

First Last

Date of Birth

Social Security #

Do you have legal custody?

Yes

No

Joint Custody

Last grade completed

If you have other children or a comment about your children or special needs, please enter it here.

Work History

Please provide information for the last 3 years.

Employer *

Wage *

Address *

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

Describe your job and your reason for leaving. *

Employer #2

Wage

Address

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

Describe your job and your reason for leaving. *

Additional employers or employment information. If there is none, put "none".

Animal Information

Please list the animals that you will bring with you.

Total number of animals *

Check all that apply. If you are accepted to LGR, you will be required to provide additional information about your animals and possibly prove ownership. *

Horse

Other livestock

Dog

Cat

Exotic

Reptile/amphibian/fish

Small caged mammal

Other not listed

Current Situation and Exit Strategy

Describe your current situation in detail.

Will you be able to transport yourself or will you need assistance?

How will your abuser react when you leave? Do you expect violence, stalking, harrassment, etc?

What do you expect to be able to accomplish if you are accepted to Littlegrass Ranch?

What are your plans and goals for your life without your abuser?

I certify that the imformation provided on this application is true and accurate. By entering your name in this field you are making an electronic signature.

Email *