Application of Interest
We are pleased to offer you the opportunity to express your interest in having your child enrolled into our school program. This is a preliminary form and is for informational purposes only. This application does not secure a placement in our school. Submission of this application will place you on our waiting list, and you will receive notification when a placement is available.
We look forward to contacting you in the near future.
Our warmest regards,
Debora Harris & Nicole Dibra
Debora Harris BCABA & Nicole Dibra
Founders & Executive Directors of The ELIJA School
The ELIJA School is a non-profit 501 (c)3, Established in September of 2006
Application of Interest
Please print out & fill out ONLY this form in it’s entirety. Incomplete applications will not be considered.
PLEASE DO NOT SEND ANY OTHER FORMS OR LETTERS WITH THIS APPLICATION OF INTEREST
Mail to: The ELIJA School 665 N. Newbridge Road Levittown, NY 11756 Attn: Admissions
Today’s Date:___________
Parent- Guardian information
Mother/Legal Guardian: _____________________________________________________
Address:_____________________________________________________________________
Home Phone:(_____)_____________ Work Phone:(_____)____________ Cell: (_____)____________
Email: ______________________________________________________________________________
Occupation: ____________________________________Title: ____________________________
Employer:____________________________________________________________________________
Father/Legal Guardian: _____________________________________________________
Address:_____________________________________________________________________
Home Phone:(_____)_____________ Work Phone:(_____)____________ Cell: (_____)____________
Email: ______________________________________________________________________________
Occupation: ____________________________________Title: ____________________________
Employer: ________________________________________________________________________
Child Information
Child's Name: _______________________________________________________________
(First) (Middle) (Last)
Date of Birth: ___________________ ___ Male ___Female
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? _________________________________________
Please give us a brief description of your child:
___________________________________________________________________________ ____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
How did you hear about our school?______________________________________________
____________________________________________________________________________
Any additional comments:_______________________________________________________
____________________________________________________________________________
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