Apply Online Download PDF Version of Application here Application for Residence Make SURE that you read and understand this application correctly. Failure do so can result in dismissal from program. First Name(Required) Last Name(Required) Email Phone(Required)Age(Required) Identify your addiction(Required) Alcoholic Drug addict I allege to not have a chemical dependency addiction Have you ever applied for disability or been on disability? (receiving payment from federal or state government disability)(Required) Yes No Have you ever been convicted of a major violent crime, for example murder, manslaughter or aggravated assault?(Required) Yes No Please explain(Required)Have you ever been charged or convicted of a sex crime?(Required) Yes No Do you have any medical or dental problems that you will need to leave facility to take care of in the next 3 months?(Required) Yes No Please explain(Required)Do you have any legal issues that will need to be taken care of in the next 3 months?(Required) Yes No Please explain(Required)Answer the following mental health, health and general:Have you EVER been told that you were Bi‐Polar?(Required) Yes No Have you EVER been told that you have PT (post traumatic) or SD (stress disorder)?(Required) Yes No Have you EVER been told that you have Major Depression or Panic Disorder?(Required) Yes No Do you have problems with Authority?(Required) Yes No Have you ever applied for Disability?(Required) Yes No Please explain(Required)Tell us about yourself:(Required)Why do you want to live at JC's Ranch?(Required)What is your relationship with Jesus Christ? Do you know him?(Required)What would you consider to be your strong points?(Required)What would you consider to be your weak points?(Required)Is there any reason that you cannot work, be on your feet and be productive while at JC’s Ranch?(Required) Yes No Please explain(Required)Do you have any problems following instructions and abiding by rules and regulations and doing what is asked of you?(Required) Yes No Please explain(Required)What goals do you have in mind to accomplish by residing at JC's Ranch?(Required)Have you ever considered suicide?(Required) Yes No Please explain(Required)Have you ever attempted suicide?(Required) Yes No When and what method?(Required)Do you feel suicidal at this time?(Required) Yes No How do you feel about being required to attend church, Recovery meetings and meeting curfews?(Required)Do you or your family member suffer from Nervous breakdown? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Migraine Headaches? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Hallucinations/delusions/visions? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Alcoholism? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Bizarre behaviors? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Nervousness? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Sleeping problems/insomnia? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Epilepsy/convulsions? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Chronic physical pain? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Memory lapses? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Drug addiction? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Psychiatric problems? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from High stress? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from Excessive eating? Me My family member Name of family member(Required) Relation of family member(Required) Do you or your family member suffer from any other medical condition? Me My family member Specify medical conditions(Required) Name of family member(Required) Relation of family member(Required) Have you ever tested positive for HIV, TB or Hepatitis?(Required) Yes No Please explain(Required)Medication DetailsName of medicationsDosageTaken how oftenCondition prescribed for Add RemoveResident Legal InfoDate Interviewed Month Day Year Date Entered Program Month Day Year Graduation Date Month Day Year Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you a legal citzen?(Required) Yes No SS#(Required) Are you currently on Parole/Probation?(Required) Yes No Give specific details(Required)Name of Parole/Probation Officer(Required) Address(Required) Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Fax Do you have any pending legal issues?(Required) Yes No Please explain(Required)Are you mandated to JC's Ranch?(Required) Yes No By whom(Required) How long?(Required) Birthdate(Required) Month Day Year Marital status(Required) S M SEP D Race(Required) Height(Required) Weight(Required) Eye Color(Required) Contacts/glasses(Required) Hair Color(Required) Do you have any Tattoos?(Required) Yes No Do you have any Piercings?(Required) Yes No Do you have any Scars?(Required) Yes No Describe:(Required)Emergency ContactName Relationship Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneCellMedical HistoryPhysician name PhoneInsurance List all Medical ConditionsList all MedicationsHave you ever been diagnosed with- Major Depression Bi‐Polar Disorder Panic Disorder Personality Disorder Post Traumatic Stress Disorder Schizophrenia OCD Any other Disorder Who treated you When were you treated Drug(s) of Choice Sobriety Date Month Day Year Have you ever been in treatment before?(Required) Yes No How many times?(Required) Where have you previously been in treatment?(Required) Do you or have you attended Church?(Required) Yes No Do you want a closer relationship with Jesus?(Required) Yes No Do you understand that you will be required to attend ALL meetings and that you will be required to be trained and disciplined under supervision to work 40 hrs. each week?(Required) Yes No Will you make a commitment to stay at JC's Ranch for 12 months?(Required) Yes No PLEASE RATE YOUR SKILL LEVEL 1‐5 (5 BEING BEST)CarpentryMasonryElectricalRoofingLandscapingComputerCookingOfficeMechanicSmall EnginePlumbingMachine OperatorWeldingAppliance RepairWood WorkingFarm WorkerGardeningChain SawList any other job skillsAre you disabled?(Required) Yes No Please explain(Required)Is there any other reason why you cannot work(Required)JC’s Ranch, Inc. requires that for a resident to be eligible to leave campus you must list up to three contacts that would visit and provide transportation for weekend and Sunday (Metter) passes. There contacts you list must be family or close acquaintances and will be strictly interviewed for continued approval. At anytime contacts may be reviewed and rejected.Contact 1 Name Contact 1 PhoneContact 1 Relation Contact 1 Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 2 Name Contact 2 PhoneContact 2 Relation Contact 2 Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact 3 Name Contact 3 PhoneContact 3 Relation Contact 3 Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Terms of Service(Required)Policy and Procedures The decision for residency will be based on completion and approval of an application. Individual’s observed behaviors within the institutions, jails, and recommendations from the courts or those of integrity within our community or ministry programs will be considered. The men at JC’s Ranch are expected to obtain jobs, pay rent, fines, court costs and probation/parole fees. The men will meet the requirements of their probation/parole officers or the court. The men are expected to become involved in a local community church that will be designated used for JC’s Ranch and become active in recovery meetings. JC’s Ranch is designed to be a 12 month program. JC’s Ranch will offer Celebrate Recovery and Celebrated Recovery 12‐step program. These guidelines are intended to move men towards self‐sufficiency instead of enabling dependency. Failure to follow guidelines will result in sanctions. * Three sanctions is an automatic dismissal from JC’s Ranch. Rules and Guidelines Church attendance is mandatory. Recovery program attendance is mandatory. Celebrate Recovery meetings are weekly. There is zero tolerance for missing R meetings. If you choose to miss you will receive a sanction. Men are required to be involved in all group meetings. Recovery 12‐step, is mandatory as times are made available. Work 12 steps and get honest with yourself and others. There will be zero tolerance for drug or alcohol usage. Random drug tests are to be expected and the refusal of one is automatic dismissal from program. If you get a confirmed positive, you are automatically dismissed from JC’s Ranch. Curfews are as follows: All residents will respect a 10pm quiet time. All public areas close at 11pm. For any resident at JC’s Ranch, a request for a night or weekend pass will be made to Director of JC’s Ranch. Each resident must keep his personal habitat sanitary and neat. This includes the making of beds each morning. All residents will be awake and out of bed by 7am each weekday morning. All residents are responsible for the cleanliness, appearance, and maintenance of their respective houses. Cleaning meetings will be scheduled if this is not adhered to. Jobs are mandatory. All residents must work a full time 40 hour/week job. Prior to any change in employment a full 2 week notice will be given.(failure to do so could result in sanctions from JC’s Ranch.) Education is an option for the men however; men are expected to work while attending school. Must have good attitude and a teachable spirit. Develop a daily prayer life and regular time in the Bible. No resident is allowed to go home during first 90 days. For the first 6 months there is no pay, but you are required to work on the premises during this time. The cost for residing at JC’s Ranch is $750.00 per month. This covers the rent, and all utilities, the local phone bill, and three meals a day. The payments can be made once a month or divided into $187.50 weekly or $375.00 bi‐weekly. Men are responsible for purchasing their own snacks. Sharing or not sharing snacks must be clearly communicated to the other men in the house. If the resident does not begin to take responsibility for their financial obligations by the 6th month of residing at JC’s Ranch, then the resident will be asked to meet with the director/board member and discuss reasons and may be asked to leave. The resident will turn in checks from pay to JC’s Ranch to be held in a bank account for resident. An allowance will be giving weekly. Visitation with family and children is highly encouraged. Failure to comply with rules and regulations of JC’s Ranch will result in immediate dismissal from JC’s Ranch. Disrespecting the program regulations that are keeping you out of prison is unacceptable and will not be tolerated. No smoking in any facility. No tobacco use of any type allowed indoors. Smoking permitted in designated areas only. Destruction of personal or JC’s Ranch property, whether intentional or otherwise is grounds for automatic dismissal. No weapons of any type allowed on JC’s Ranch property by the resident. No Gambling allowed in JC’s Ranch facility. No Pornography allowed in any JC’s Ranch facility. Residents who do not have full time employment are required to attend the morning, noon and evening devotion held Mon‐Sat. No females are allowed on JC’s Ranch property at any time, except the main house during scheduled times. All residents are responsible for the completion of their assigned chore. Disrespecting, lying to, defying, or any other non‐complying behavior toward staff is grounds for disciplinary action or automatic dismissal. New residents are not allowed to leave the property alone for 30 days. After 90 days a resident may request evaluation for the purpose of a weekend pass. One weekend pass per month, per resident. No unauthorized prescription medications are allowed. No alcohol based personal hygiene products. All medications will be discussed prior to admission. Failure to comply means automatic dismissal. Resident must eat meals at main house when on premises. Accountability boards will be used by all residents in each facility. Failure to comply will result in extra chores, house restriction, and/or automatic dismissal. Head shops, CBD products, Bars, Discos or otherwise are off limits to all residents. No cell phone, food or tobacco use during any Group therapy or Mandatory outside meeting. Do not go anywhere without permission and always have a responsible student or staff member with you. Limited phone calls‐you are allowed a 15 min. call on Saturday‐this is a privilege and not a given that it will happen every Saturday it is NOT a right. No student may have their own personal car until after graduation. **Program Policies and procedures are subject to change at director’s discretion. Standard of Conduct “The standard of conduct expected from each resident is to respect JC’s Ranch and the other residents at JC’s Ranch and the neighbors in the neighborhood surrounding JC’s Ranch. The following scripture is the basis for the standards set for JC’s Ranch houses: But the Holy Spirit produces this kind for fruit in our lives: love, joy, peace, patience, kindness, goodness, faithfulness, 23 gentleness, and self‐control. There is no law against these things! Galatians 5:22‐23 Courteous to others – example: the residents are watching television, or eating dinner together and a phone rings, please leave the area to talk on the phone as not to disturb others. Responsible for keeping your areas clean after you use them, kitchen, bathroom, etc. The television and music must be at a reasonable volume as not to disturb others. Each resident must be considerate of the other residents. If a roommate is in bed, be courteous and be quiet. No phone communications after 10pm. Emergency purposes only after this time. No meddling in other residents personal belongings. No Stealing. Honesty is expected. Lying/withholding information will be sanctioned. No physical violence or threat of violence by any residents will be tolerated either on or off JC’s Ranch. property. Fighting means automatic dismissal. No loud outburst. No cell phones for the first 11 months (this is not automatic this based on each individual). 30 minute on phone calls. Minor problems need to be handled with the house manager. Medium to more severe problems need to be first brought to the house manager and David. There are to be no secrets. Secrets are avoidance of telling the truth, and this is called lying by omission and will not be tolerated. These guidelines have been prayed over and put in place for your own protection and to provide a safe place for you to transition back into society. Only if you feel you can live within the boundaries of this contract should you sign below. The last step in successful recovery is to service others. The men residing at JC’s Ranch will be expected to give back and fulfill the call to serve others. I understand that when you are accepted into the program at JC’s Ranch (mandated by court or not) the only reason you will need to be dismissed from JC’s Ranch will be that one or both of us believe this program does not meet your needs. You must realize this program does not suit everyone’s needs nor is this program for everyone. Different men have different needs and if it is determined that you need more than this program is equipped to provide, you will be terminated from JC’s Ranch immediately and no explanation will be needed nor will one be given to satisfy the Court, or your Probation officer or anyone else. I FULLY UNDERSTAND all the questions that I have read and answered above. We the board of directors for JC’s Ranch, Inc. David and Shelly Clifton are not responsible for stolen or destroyed items or damages accrued while living at JC’s Ranch. Executive Director: David Clifton912.313.0114Board of Directors include Wayne Hillis, Sr., Michael Weeks, Michelle Clifton VEHICLE Driving a vehicle belonging to JC’s Ranch, Inc. is strictly prohibited if your license is suspended, invalid for ANY reason or you do not have them with you or on you at time of driving. You must have PERMISSION to drive any vehicle EACH TIME from David Clifton. Earned Leave – This is a privilege Residents, who have diligently worked on their program, have continued to have a good attitude and have been prompt to all scheduled assignments, has attended all meetings and has abided by all JC’s Ranch rules may EARN leave time. After 90 Days ‐‐‐‐‐ 24 hour passAfter 120 Days ‐‐‐‐‐ 48 hour pass Drug testing will be done on return residents and $10.00 (to cover testing) must be paid when leave is requested. AGREEMENT TO GUIDELINES AND RULES I agree to all the rules and regulations set forth by JC’s Ranch, Inc.. I have been advised that if I do not comply with all rules and regulations, I will be subject to immediate dismissal. I will be subject to random drug and alcohol screens. I understand that if there is a positive result I am subject to immediate dismissal. Refusing to take a drug or alcohol test will result in immediate dismissal. PICTURES I agree for JC’s Ranch, Inc. to take pictures of general daily activities that I may be involved in. JC’s Ranch, Inc. may use these pictures for web‐site or advertisements. MEDICAL PROTOCOL – ALCOHOL AND DRUG TEST Before entering JC’s Ranch, Inc. please take care of all medical and dental needs. You must have a negative test for TB, Hepatitis, HIV and COVID‐19. JC’s Ranch, Inc. will not be responsible for any medical needs nor are we responsible for transportation. However, if there is an emergency, a staff member will get you to the emergency room. You will be responsible for all medical expenses. RELEASE OF LIABILITY I hereby release from liability and shall hold harmless JC’s Ranch, Inc., David and Michelle Clifton and all board members for JC’s Ranch Inc. for any accident I may become involved in during my stay. I am here of my own free will and I am free to leave at any time I desire. I further understand that JC’s Ranch, Inc., David and Michelle Clifton and all board members for JC’s Ranch, Inc. assume no responsibility for any medical conditions or medical bills I may incur. Driving a vehicle belonging to JC’s Ranch, Inc. is strictly prohibited if your license is suspended, invalid for ANY reason or you do not have them with you or on you at time of driving. You must have PERMISSION to drive any vehicle EACH TIME from David Clifton. JC’s Ranch, Inc. requires that for a resident to be eligible to leave campus you must list up to three contacts that would visit and provide transportation for weekend and Sunday (Metter) passes. There contacts you list must be family or close acquaintances and will be strictly interviewed for continued approval. At anytime contacts may be reviewed and rejected. CELL PHONE POLICY Cell phones are a privilege and this privilege can be revoked at any time. Cell phones are allowed for use by residents after 11 months. (this is not automatic this based on each individual)Residents are not allowed to use cell phones during the hours of 8 AM to 5 PM and they are not allowed during meetings or church. Phones will be checked by staff for pornography, illicit materials. If it is found that a resident is using a cell phone at times not allowed or for inappropriate reasons the phone will be confiscated and a search performed. If it is deemed that the phone was used inappropriately or at times not allowed then privileges will be revoked and the phone will be confiscated. Refusal to comply with this policy can and will lead to dismissal from the program. I agree to the Terms of Service Δ