Resident Applicaiton | rockbottomranch.org

There are now 2 options for submitting a resident application. Option 1 below, is to print, fill out by hand, and mail in your application. Option 2 is to scroll on down the page, and fill out the online, fill in the blank version, and submit it online.

Please click on the button below to
download the resident application.

Applications can be mailed to us at

P.O. Box 3482, Palestine, Texas, 75802

*You may also fill out the "fill in the blank" form below if you prefer to submit online rather than printing and mailing it.

Rock Bottom Ranch
Online Resident Application

First Name

Last Name

Your Phone Number

Who Referred You?

Birthday

Height

Weight

Race

Home Town

Name and Relation of 4 Closest Family Members

Do you have boyfriend?

Yes

How many children do you have?

Do you have custody?

When did you last use drugs? (list tye of drugs)

When did you last use alcohol?

When did you last use tobacco?

List All Medications (please separate by comma)

List All Physical and Mental Health Probems

Any pending court cases?

Yes

If so, please enter county, court date, and name & number of attorney here.

Are you currently incarcerated?

Yes

If so, what is your expected release date?

Name & Number of Probation or Parole Officer. (If applicable)

List entire criminal history by naming each charge and time spent in jail or prison for each offense.

Why do you want to reside at Rock Bottom Ranch?

Are you willing to commit yourself to this program for a year?

Yes

Do you have a relationship with Jesus? (Please describe)

List any special talents, giftings or abilities.

Release of information:

I hereby authorize Rock Bottom Ranch to obtain any information pertaining to any charges, convictions, medical data and personal information. I also give Rock Bottom Ranch to gather information under any other name or alias on this form.

Social Security Number:

Your Signature

You will be informed of any decision that is made and will be provided with a letter for lawyer, judge, parole, etc.

There are now 2 options for submitting a resident application. Option 1 below, is to print, fill out by hand, and mail in your application. Option 2 is to scroll on down the page, and fill out the online, fill in the blank version, and submit it online.

Please click on the button below to download the resident application.

Rock Bottom Ranch Online Resident Application

Please click on the button below to
download the resident application.

Rock Bottom Ranch
Online Resident Application