Programs

Outreach Application

All fields are required except where indicated.

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'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 *

How did you hear about The ELIJA School for Autism? *

Please give us a brief description of your child: *

Any additional comments: *

Submit

* indicates a required field.

Upcoming

Special Events

Competing for the ELIJA School in 2024!

December 15, 2023 - Ongoing

ELIJA Farm's 2024 Apple Pie Sale

November 26, 2024 9:00am - November 27, 2024 5:00pm

Special Events

Fall Festival 2024

October 26, 2024 10:00am - 3:00pm

LIBAC 2024

December 5, 2024 8:00am - December 6, 2024 4:00pm

Help Drive Our Mission Forward

With the help of your funds and through the efforts of our Foundation and our School we strive to make a difference:

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