School Application

About Us

Please complete this form in its entirety. Incomplete applications will not be considered.
PLEASE DO NOT SEND ANY OTHER FORMS OR LETTERS WITH THIS APPLICATION OF INTEREST

All fields are required except where indicated.

Parent/Guardian Information

Mother/Legal Guardian Name (first and last):

Address 1:

Address 2: (optional)

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Occupation:

Title:

Employer:

Father/Legal Guardian Name (first and last):

Address 1:

Address 2: (optional)

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Email:

Occupation:

Title:

Employer:

Child Information

Child's Name (first, last and middle):

Date of Birth:

Diagnosis:

Date of Diagnosis:

Diagnosis given by:

Affiliated With:

Town and State of Diagnostician:

Other Conditions:

Current Placement:

Additional Information

How did you hear about The ELIJA School for Autism?

Please give us a brief description of your child:

Any additional comments: