Interest Form

SCHEDULE A TOUR

FOR CURRENT FAMILIES

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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?