Registration: Life Impact Ministries

If you have not yet registered for access to our online scheduling system, please complete the following form.

* required field
APPLICANT INFORMATION
 

ADDITIONAL INFORMATION
* Birthdate
* Best way to reach you:
* Emergency Contact
* Emergency Contact Phone
* Emergency Contact Relationship



Thank you for your interest!
 
 
Shrewsbury, Pennsylvania 17361
412-841-8033
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