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REACH - Online Program

Student First Name *

Student Last name *

Student Birth Date *

Program Interest *

REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact Information:

Parent First Name *

Parent Last name *

Parent Mailing Address (Street Address, City, State, Zip) *

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Cell:

Email *

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ASAT/CHW - Online Program

Student First Name *

Student Last name *

Student Birth Date *

Program Interest *

REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact Information:

Parent First Name *

Parent Last name *

Parent Mailing Address (Street Address, City, State, Zip) *

Home Ph:

Work Ph:

Cell:

Email *

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CLP - Online Program

Student First Name *

Student Last name *

Student Birth Date *

Program Interest *

REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact Information:

Parent First Name *

Parent Last name *

Parent Mailing Address (Street Address, City, State, Zip) *

Home Ph:

Work Ph:

Cell:

Email *

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Stay Safe - Online Program

Student First Name *

Student Last name *

Student Birth Date *

Diagnosis:

1.

2.

3.

4.

5.

6.

Parent Contact & Billing Information:

Parent First Name *

First

Parent Last name *

Last

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

Home Ph:

Work Ph:

Cell:

Email *

Other Emergency Contact:

Emergency Contact name *

Phone *

Email *

Special Needs or Considerations:

Program Interest *

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 *

Student Last name *

Student Birth Date *

Program Interest *

REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact & Information:

Parent First Name *

Parent Last name *

Parent Mailing Address (Street Address, City, State, Zip) *

Home Ph:

Work Ph:

Cell:

Email *

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Wellness - Online Program

Student First Name *

Student Last name *

Student Birth Date *

Program Interest *

REACH

CLP

REC

ASAT/CHW

Please list the classes student is interested in *

Parent Contact & Information:

Parent First Name *

Parent Last name *

Parent Mailing Address (Street Address, City, State, Zip) *

Home Ph:

Work Ph:

Cell:

Email *

If you are human, leave this field blank.

Pete & Jerry Rossman

Helpful Info

Connect & Get Started

Chapel Haven Programs

Chapel Haven Schleifer Center

Chapel Haven West

Upcoming Events

Grab a cup of coffee and join us Saturday, March 13 for a virtual morning open house

Chapel Haven Schleifer Center

Chapel Haven West

Upcoming Events

Grab a cup of coffee and join us Saturday, March 13 for a virtual morning open house

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!

Fill out this form to sign up!

Fill out this form to sign up!