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*
MM slash DD slash YYYY
Child Name
First Last
Birth Date of Child
MM slash DD slash YYYY
Child Name
First Last
Birth Date of Child
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.
How did you hear about our programs?

SUMMIT Early Learning offers Pre-K Counts and Head Start Preschool options,

~ both FREE for qualifying families ~

Contact Enrollment@summitel.org OR complete this form.