Camp MELC Wynnewood 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 2019 * 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 PARENT/GUARDIAN 1 INFORMATION Name * Home Phone Number * Cell Phone Number * Email Address * Home Address * City * State * Zip Code * Employer/Workplace * Work Address * Work Phone Number * PARENT/GUARDIAN 2 INFORMATION Name * Home Phone Number * Cell Phone Number * Email Address * Home Address * City * State * Zip Code * Employer/Workplace * Work Address * Work Phone Number * 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? * Please select one. Yes No Will Your Child Be Attending SPIES or ESY? * Please select one. Yes No T-Shirt Size * Please select one. Child Size X-SMALL Child Size SMALL Child Size MEDIUM Child Size LARGE Adult Size SMALL Adult Size MEDIUM Adult Size LARGE Adult Size X-LARGE Please select the session(s) needed. One Week Camp Session Fee - $290 *Part Time Session Fee - $181 *ELRC Families additional $25 + copay 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) 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.