Summer Camp Application – 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 Camp (August 11-17)
Extended Weekend ADULTS ONLY (September 11-14))

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 session is 3:00 pm; Departure time for week-long session 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 week in August is May 15^th and the deadline for the extended weekend in September is July 15^th.

COST

$150.00 for the week-long session – per adult

Non-member (legally blind): $300.00 – per adult

Non-member (sighted): $597.00 – per adult

$75.00 per child (under 18)

No charge for children under two.

$75.00 for the extended weekend – per adult

Non-member (legally blind): $150.00 – per adult

Non-member (sighted): $298.50 – per adult

Checks and money orders must be made payable to: Missouri Council of the Blind.

All fields must be completed on the application. Please forward this application, along with your check or money order (no cash, please), to:

Missouri Council of the Blind
Summer Camp Program
5453 Chippewa Street
St. Louis, MO 63109

Summer Week Camp

MCB Member, Adult - $150.00
Non-Member, Legally Blind Adult - $300.00
Non-Member, Sighted - $597.00
Child (2 - 17 years old) - $75.00

Extended Weekend Camp (Adults only)

MCB Member, Adult - $75.00
Non-member, legally blind - $150.00
Non-member, sighted - $298.50

Total

Item Quantity Qty Total

There are no products selected.

Summer Week Camp - MCB Member, Adult 1 $150.00

Summer Week Camp - Non-Member, Legally Blind Adult 1 $300.00

Summer Week Camp - Non-Member, Sighted 1 $597.00

Summer Week Camp - Child (2 - 17 years old) 1 $75.00

Extended Weekend Camp (Adults only) - MCB Member, Adult 1 $75.00

Extended Weekend Camp (Adults only) - Non-member, legally blind 1 $150.00

Extended Weekend Camp (Adults only) - Non-member, sighted 1 $298.50

Subtotal

Total $0.00

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