Camp MELC Pottstown Application – New Families If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. School Child Attends * Grade As Of September 2017 * Child's Name * Gender * Please select one. Male Female Date of Birth * Address Where Child Resides * City * State * Zip Code * Child Resides With * Both ParentsMotherFatherOther If other, please specify PARENT/GUARDIAN 1 INFORMATION Name * Home Phone * Cell Phone * Email * Home Address * City * State * Zip Code * Employer/Workplace * Work Address * Work Phone * PARENT/GUARDIAN 2 INFORMATION Name * Home Phone * Cell Phone * Email * Home Address * City * State * Zip Code * Employer/Workplace * Work Address * Work Phone * How Did You Hear About Camp MELC? * Please select one. CCIS Currently enrolled child Facebook Google Search Mainline Media School District Word of mouth Other If you selected other, please specify: Please briefly describe any special needs, allergies or disabilities of your child. * Does your child have an IEP? * Please select one. Yes No Do you have CCIS? * Yes No Please select one. T-Shirt Size * Please select one. Child Size SMALL Child Size MEDIUM Child Size LARGE Adult Size SMALL Adult Sizme MEDIUM Adult Size LARGE Adult Size X-LARGE Please select the session(s) you wish to sign up for and mark the expected hours of care needed. Camp Fee Per Weekly Session - $182 *Fee includes a maximum 10 hours of care daily and all activities and trips. Early Bird Discount: Register by May 2nd and receive a 5% tuition discount All Summer Discount: Pay in full by June 22nd and receive a 3% tuition discount Choose Your Session(s) * You may select multiple camp sessions. Use Control + Shift on your keyboard to select multiple sessions. Session 1 (June 19-June 23) Session 2 (June 26-June 30) Session 3 (July 3-July 7) Session 4 (July 10-July 14) Session 5 (July 17-July 21) Session 6 (July 24-July 28) Session 7 (July 31-August 4) Session 8 (August 7-August 11) Session 9 (August 14-August 18) Session 10 (August 21-August 25) COMPLETE YOUR APPLICATION FEE PAYMENT ON THE NEXT PAGE: In order to complete the registration process for this session you'll need to complete a payment for the $25 application fee on the next page. If this payment is not completed, your application will not be accepted Application Fee (Required) If you are a human and are seeing this field, please leave it blank.