Interest Form

"*" indicates required fields

Parent/Caregiver Name*

First Last

Date

Address

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

Phone*

Email

Child Name*

First Last

Birth Date of Child*

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

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

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?

Would you like to be added to our email mailing list to stay updated on what's happening at SUMMIT?

YES

NO