665 Newbridge Road Levittown NY 11756

www.elija.org Phone: 516 433 4321 Fax:516 433 4324

NEED BASED SCHOLARSHIP FORM FOR ELIJA WORKSHOPS

Print out this page and Mail it to us.

MUST BE ACCOMPANIED WITH REGISTRATION FORM

The purpose of this form is to submit a registration form to an ELIJA affiliated workshop, which will not be accompanied with the set registration fee. ELIJA would like to give fair access to all interested educators,professionals students, parents and caregivers of children with Autistic Spectrum Disorders or related disabilities, to attend our workshops who otherwise would not be financially able to afford the entrance fee.

Please tell us how you are affiliated with the field of Autism, developmental disabilities and Applied Behavior Analysis:

____ I am a Parent or Caregiver

____ I am a Student

____ I am a professional (Special Educator, speech therapist, behavior analyst etc)

Please Briefly describe your necessity in being awarded a need basis scholarship for this workshop:

_____________________________________________________________________________

We ask for any monetary donation in any amount that you can contribute if possible.

I would like to contribute $__________ (Check or Money Order)

_______ I will be needing transportation to attend this conference

Name:___________________________________

Address:_________________________________

City State and Zip:__________________________

Phone #:__________________________________

Email:____________________________________

ELIJA will take into account your necessities and review your application on a case by case, first come first serve basis . Please submit this form with a completed registration fee and if applicable , your voluntary contribution. If you are approved you will be contacted, if you are not, for whatever reason, your contribution will be returned to you. Thank you for your interest.

In many cases You will NOT Be notified about an awarded scholarship until 1 week prior to the workshop. It is usually best to submit this applictaion 1 month in advance if possible.

THE ELIJA FOUNDATION