Camp MELC Pottstown Application – Current 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 2019 * 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 ELRC? * 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) needed. One Week Camp Session Fee - $192 Session fee includes a maximum 10 hours of care daily and all activities/trips. Choose Your Session(s) * You may select multiple camp sessions. Use Control + Shift on your keyboard to select multiple sessions. Session 1 (June 17-June 21) Session 2 (June 24-June 28) Session 3 (July 1-July 5) *No camp on July 4* Session 4 (July 8-July 12) Session 5 (July 15-July 19) Session 6 (July 22-July 26) Session 7 (July 29-August 2) Session 8 (August 5-August 9) Session 9 (August 12-August 16) Session 10 (August 19-August 23) If you are a human and are seeing this field, please leave it blank.