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FOR CURRENT FAMILIES
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About
COVID-19
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Programs
Age 0 – 3
Age 3 – 5
K – Age 12
Enrollment
Schedule a Tour
Interest Form
Employment
Current Opportunities
What Staff Have To Say
Ways to Give
Menu
Home
About
COVID-19
Locations
News
Board of Directors
SUMMIT Leadership
Programs
Age 0 – 3
Age 3 – 5
K – Age 12
Enrollment
Schedule a Tour
Interest Form
Employment
Current Opportunities
What Staff Have To Say
Ways to Give
Interest Form
"
*
" 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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