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

Early Learning Programs for Birth through Age 12

We offer early childhood services to meet the needs of all families.

If you are interested in parenting or early childhood educational services – in the home (where we bring services to you) or in a classroom setting – let us know!

FILL OUT THIS FORM & someone will contact you!