Application

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: