Summer Camp Application Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Applicant General InformationName *FirstLastEmail *PhoneAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Birth (Month, Day, Year)Vision StatusTotally BlindLegally BlindSightedDo you have a Guide Dog?YesNoMembershipPlease choose:AffiliateMember At LargeNot a MemberIf a member of an affiliate, please list which affiliate.Health InformationOther disabilities, please list below:Are you restricted or unrestricted from using stairs?RestrictedUnrestrictedAllergies (including food and medicine)Please list medicationsPhysician NamePhysician Phone NumberPhysician's addressEmergency Contact InfoEmergency Contact Name *Emergency Contact PhoneRelationshipEmergency Contact AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCamp SelectionSelect your choiceWeek 1 (June 3-9)Week 2 (July 29-Aug 4)Extended Weekend 1 (June 6-9)Extended Weekend 2 (Aug 1-4)Please note any special requests due to health problems, cabin placement, etc.By checking this box, I certify I have read and agree to Guidelines for the Summer Camp Program. I am attending summer camp at Cobblestone Lodge at my own risk and will not hold the Missouri Council of the Blind liable for my health or safety while in attendance.YeseSignature by typing your first and last name hereToday's Date (Month, Day, Year)Note: Arrival time for week-long sessions is 3:00 pm; Departure time for week-long sessions is 9:00 am. Arrival and departure times for Extended Weekend is after 3:00 pm on Thursday and departure is 9:00 a.m. on Sunday. The deadline for submitting applications for the June week long and June extended week-end is March 15. Deadline for second week and week-end is May 1st . COST $100.00 for the week-long session – per adult $90.00 per child (under 18) Non-member (legally blind): $200.00 – per adult Non-member (sighted): $570.00 – per adult $75.00 for the extended weekend – per adult Non-member (legally blind): $150.00 – per adult Non-member (sighted): $332.00 – per adult No charge for children under two. Checks and money orders must be made payable to: Missouri Council of the Blind. All fields must be completed on application. Please submit this online application, and then send your check or money order (no cash please) to: Missouri Council of the Blind Summer Camp Program 5453 Chippewa Street St. Louis, MO 63109 Submit Skip back to main navigation