Local Affiliates

Members-At-Large, please use this form, leaving the affiliate specific fields blank.

Affiliates: You can use this form to enter all your affiliate members at the beginning of your membership year, when your dues are required, and when you add in a new member. We will use this information to put in our database and to report to ACB in February.

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email

Affiliate

Level of Blindness

Missouri Chronicle Format Preference

Birthday

Current Dues Paid

Dues Paid Payment Method

Cash
Check
Credit Card or Online

Reason for Joining

Mobility Aids

Sighted Guide
Guide Dog
White Cane

Do you have dual sensory loss?

Yes
No

Are you interested in serving on a committee for MCB or this affiliate?

Yes
No

If yes, please select your interests below. To see more details on the committees see https://moblind.org/mcb-committees/

Skills and Strengths

Other

Affiliate's Board of Directors (only needs to be submitted once, preferably with the Secretary or President's individual entry above).

Optional Demographic Statistical Data for ACB

Gender

Male
Female

Ethnicity

Hispanic/Latino
Not Hispanic/Latino

Race

Veteran Status

4-Rivers

Agape Council of the Blind

Allied Workers for the Blind

Heritage

River City Workers of the Blind

Southeast United Blind

SWMoVC (Southwest Missouri Vision Connections)

United Workers for the Blind

Members-At-Large, please use this form, leaving the affiliate specific fields blank.

Affiliates: You can use this form to enter all your affiliate members at the beginning of your membership year, when your dues are required, and when you add in a new member. We will use this information to put in our database and to report to ACB in February.

Optional Demographic Statistical Data for ACB