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REACH - Online Program

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Student Birth Date *

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REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

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ASAT/CHW - Online Program

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REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact Information:

Parent First Name *

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Email *

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CLP - Online Program

Student First Name *

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REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact Information:

Parent First Name *

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Stay Safe - Online Program

Student First Name *

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Diagnosis:

1.

2.

3.

4.

5.

6.

Parent Contact & Billing Information:

Parent First Name *

First

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Last

Address (street address, town, city, zip) *

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Other Emergency Contact:

Emergency Contact name *

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Special Needs or Considerations:

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REACH

CLP

REC

ASAT/CHW

Name of class student is applying for: *

Currently enrolled in high school or post-secondary program? If yes, please list school: *

Tell us how you heard about Chapel Haven:

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RecDesk - Online Program

Student First Name *

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REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact & Information:

Parent First Name *

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Wellness - Online Program

Student First Name *

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REACH

CLP

REC

ASAT/CHW

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Parent Contact & Information:

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Home Ph:

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Pete & Jerry Rossman

Helpful Info

Connect & Get Started

Chapel Haven Programs

Chapel Haven Schleifer Center

Chapel Haven West

Upcoming Events

Chapel Haven Schleifer Center to “step up” for Down Syndrome Awareness with Walk planned for September 26

Chapel Haven’s Golf Tournament is ON!

Chapel Haven Schleifer Center

Chapel Haven West

Upcoming Events

Chapel Haven Schleifer Center to “step up” for Down Syndrome Awareness with Walk planned for September 26

Chapel Haven’s Golf Tournament is ON!

Fill out this form to sign up for classes!

Fill out this form to sign up for classes!

Fill out this form to sign up for classes!

Fill out this form to sign up for classes!

Fill out this form to sign up!

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