DATE OF BIRTH:  (day/month/year)

ADDRESS:            

CITY:                    

STATE:                 

ZIP CODE:           

PHONE                

AFFILIATED? Yes or No:

IF YES, WHAT AFFILIATE?: 

DEGREE OF BLINDNESS:  (total, legal, sighted)

OTHER List Other Disabilities:         

Please indicate if your physical/orthopedic problems restrict your mobility for climbing stairs
PLEASE STATE IF YOU ARE RESTRICTED OR UNRESTRICTED FROM USING STAIRS: 

ARE YOU ALLERGIC TO ANY MEDICATION? yes or no:   

IF YES, PLEASE EXPLAIN: 

LIST ALL MEDICATION YOU ARE TAKING:  

PHYSICIANS NAME:         

ADDRESS:                           

CITY:                                   

STATE:                                

ZIP CODE:                          

PHONE:                              

EMERGENCY CONTACT INFORMATION

NAME:                         

ADDRESS:                   

CITY:                           

STATE:                        

ZIP CODE:                   

PHONE:                       

WEEK PREFERRED:

FIRST WEEK June 1-8:                     

SECOND WEEK July 20-27:               

EXTENDED WEEKEND September 11-14:   

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.
 

NOTE: Arrival time for week-long sessions is 3:00 p.m. departure time for week-long sessions is 9:00 a.m.

Arrival and departure times for Extended Weekend are after 6:00 p.m. on Thursday evening and after the
noon meal on Sunday.

The deadline for submitting applications for the weekly sessions is May 1.
The deadline for submitting an application for the Extended Weekend is August 1.

COST:

Cost per adult $60 for the week-long session and $35.00 for the extended weekend.
Cost per child under 18 is $50.00. No charge for children two and under.

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


Applicant’s signature ______________________________________________________________

Date __________________________________________________________________________

Please forward this application, along with your check or money order (no cash) to:

For information on where to mail this application, please call: 314-832-7172 or the toll free number: 800-342-5632.