2019-2020 MELC Colonial School Age Programs Application If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Elementary School Child Attends * Grade As Of September 2019 * Desired Start Date * Child's Name * Gender * Please select one. Male Female Birth Date * Address Where Child Resides * City * State * Zip Code * Child Resides With * Both ParentsMotherFatherOther If other, please specify Primary Language Spoken at Home * 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 * 2019-2020 Care Please select the care needed for the 2019-2020 school year. * Please select one. Before Care Only (7-9 AM) After Care Only (3:20-6 PM) Before and After Care (7-9 AM and 3:20-6 PM) If you are enrolling in part-time care, please select the 3 days you will need care (minimum of 3 days/week). * Use Control + Shift on your keyboard to select multiple sessions. Monday - Before Care Monday - After Care Monday - Before & After Care Tuesday - Before Care Tuesday - After Care Tuesday - Before & After Care Wednesday - Before Care Wednesday - After Care Wednesday - Before & After Care Thursday - Before Care Thursday - After Care Thursday - Before & After Care Friday - Before Care Friday - After Care Friday - Before & After Care Does your child have an IEP? * Please select one. Yes No Do you have CCIS? * Yes No Please select one. Please briefly describe any special needs, allergies or disabilities of your child. 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.