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?