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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?
Would you like to be added to our email mailing list to stay updated on what's happening at SUMMIT?
YES
NO
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