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Manet Community Health Center at APS Welcome Center
The APS Welcome Center is pleased to partner with Manet Community Health Center to offer intake appointments and insurance navigation services to all APS families. Please complete the form below to schedule an appointment. All appointments will take place at the APS Welcome Center, located in Attleboro High School.
Parent/Guardian Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Date of Birth
-
Month
-
Day
Year
Date
Student Name(s)
Student School(s). Select all that apply.
Early Learning Center
Hill Roberts Elementary
Hyman Fine Elementary
Studley Elementary
Thacher Elementary
Willett Elementary
Brennan Middle School
Coelho Middle School
Wamsutta Middle School
Attleboro High School
Attleboro Community Academy
Attleboro Virtual Academy
Network Program
Will you need an interpreter?
Yes
No
Please select your preferred language.
Please Select
Spanish
Portuguese
Chinese
Cantonese
Arabic
French
Haitian Creole
Urdu
Brazilian Portuguese
Please select your appointment type. Select all that apply:
*
Intake and Scheduling for Manet Attleboro
Insurance Navigation
Insurance Navigation, Intake and Scheduling for Manet Attleboro
Insurance Navigation and Scheduling. Please select your appointment time:
*
I agree that all information submitted within this form can be shared with Manet Community Health Center, Attleboro location.
*
Yes
No
Signature
*
Submit
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