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

Workshops & Conferences

A Pathway To Adulthood Using Self-Direction: Transitioning For Independence 2025

May 17, 2025 - Ongoing

Pave The Way To Employment 2025

April 1, 2025 - Ongoing

Taste On The Beach 2025

May 4, 2025 - 12:00pm

ELIJA's 18th Annual Sy Schwartz Golf Outing of 2025

June 2, 2025

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:

Make A Donation