Summer Camp Application Form – Missouri Council of the Blind

Applicant General Information

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth (Month, Day, Year)

Vision Status

Totally Blind
Legally Blind
Sighted

Do you have a Guide Dog?

Yes
No

Membership

Please choose:

Affiliate
Member At Large
Not a Member

If a member of an affiliate, please list which affiliate.

Health Information

Other disabilities, please list below:

Are you restricted or unrestricted from using stairs?

Restricted
Unrestricted

Allergies (including food and medicine)

Please list medications

Physician Name

Physician Phone Number

Physician's address

Emergency Contact Info

Emergency Contact Name

Emergency Contact Phone

Relationship

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Camp Selection

Select your choice

Week 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.

Yes

eSignature by typing your first and last name here

Today'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