Interest Form | SUMMIT Early Learning

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FOR CURRENT FAMILIES

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Home
About
Programs
Enrollment
- Schedule a Tour
- Interest Form
Employment
- Benefits
- What Staff Have To Say
Ways to Give

Menu

Home
About
Programs
Enrollment
- Schedule a Tour
- Interest Form
Employment
- Benefits
- What Staff Have To Say
Ways to Give

Online Interest Form

Complete the form below and one of our enrollment specialists will reach out to discuss your needs and explain next steps.

Parent/Caregiver First Name

Parent/Caregiver Last Name

Date

Address

Phone Number

Email

Child First Name #1

Child Last Name #1

Child Birth Date

Race

Black/African American American Indian or Alaskan Native Native Hawaiian or Pacific Islander Asian White

Ethnicity

Hispanic Non-Hispanic

Child First Name #2

Child Last Name #2

Child Birth Date

Race

Black/African American American Indian or Alaskan Native Native Hawaiian or Pacific Islander Asian White

Ethnicity

Hispanic Non-Hispanic

Child First Name #3

Child Last Name #3

Child Birth Date

Race

Black/African American American Indian or Alaskan Native Native Hawaiian or Pacific Islander Asian White

Ethnicity

Hispanic Non-Hispanic

Programs or Services you are interested in

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

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?