Interest Form | SUMMIT Early Learning

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Enrollment
- Schedule a Tour
- Interest Form
Employment
- Benefits
- What Staff Have To Say
Ways to Give

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Home
About
Programs
Enrollment
- Schedule a Tour
- Interest Form
Employment
- Benefits
- What Staff Have To Say
Ways to Give

Online Interest Form

Complete the form below and one of our enrollment specialists will reach out to discuss your needs and explain next steps.

"*" indicates required fields

Parent/Caregiver Name*

First Last

Date

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email

Child Name*

First Last

Birth Date of Child*

MM slash DD slash YYYY

Race

Black/African American

American Indian or Alaskan Native

Native Hawaiian or Pacific Islander

Asian

White

Ethnicity

Hispanic

Non-Hispanic

Child Name

First Last

Birth Date of Child

MM slash DD slash YYYY

Race

Black/African American

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Other

Ethnicity

Hispanic

Non-Hispanic

Child Name

First Last

Birth Date of Child

MM slash DD slash YYYY

Race

Black/African American

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Asian

White

Other

Ethnicity

Hispanic

Non-Hispanic

Programs or Services Requesting

Check all programs or services in which you may be interested.

Child Care

Preschool (Head Start or Pre-K Counts)

Early Head Start

Before and/or After School Program

Summer Camp

Please note any questions or special requests here.

For those interested in Child Care (0-5) only: Are any of the child's parents employed at Evangelical Community Hospital or Susquehanna University?

Yes

No

How did you hear about our programs?

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