Please fill in the following form as completely as possible.  This information will help us determine if F. L. Chamberlain School is right for the potential student. 

I am a:	parent/guardian  educator or professional
First name
Last name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail

Information about the potential student:

Student's First name
Last name
Date of birth
Sex:	Male Female
Medical diagnosis:
Present academic placement:
Grade   Public School  Private School
Previous psychiatric hospitalization?
	Yes No

Use the space below for other comments or questions: