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Thank you for your interest in Chapel Haven Schleifer Center!

Please fill out the form below and our Admissions Office will contact you with more information.

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Parent / Guardian Information
  • First Parent / Guardian
  • First Name *
  • Last Name *
  • Email Address *
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  • Cell Phone *
Home Address
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  • How did you hear about us?
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  • Student 1
  • First Name *
    Last Name *
  • Birthdate *
    (mm/dd/yyyy)
  • Grade Level of Interest *
    School Year *
  • Current School
  • Student's Primary Diagnosis

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