Pre-Registration Form

Parent/Caregiver Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email
Child Name*
First Last
Birth Date of Child*
Date Format: MM slash DD slash YYYY
Child Name
First Last
Birth Date of Child
Date Format: MM slash DD slash YYYY
Child Name
First Last
Birth Date of Child
Date Format: MM slash DD slash YYYY
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
- Healthy Families (Mifflin and Northumberland Counties only)
- Before and/or After School Program
- Summer Camp
Please note any questions or special requests here.