Guide Dog Foundation For The Blind, Inc.® Student Application

All information is privileged and will be considered confidential.

* Fields marked with an asterisk are required.

Section One: Demographics

Please provide your contact information.

* Name


* Street Address



* City


* State


* Zip


* Home phone


Work phone


Cell phone


E-mail address



2. Will you be at least 16 years of age when you are available for training?
* Yes No

3. If you are not fluent in English, in what language(s) are you fluent?


4. In what format would you like to receive correspondence/information from the Guide Dog Foundation? Please indicate your top three choices.

* First Choice: Print Large print Braille Email Diskette

* Second Choice: Print Large print Braille Email Diskette

Third Choice: Print Large print Braille Email Diskette

5. How did you hear about the Guide Dog Foundation?
* Please specify




SECTION TWO: PHYSICAL HISTORY
Section Two: Physical History

6. Are you legally blind?
* Yes No

7. Since when have you been blind/visually impaired?
* Please specify.


8. Please describe the cause of blindness.
*Specify.

9. Please describe any physical limitations or limiting medical conditions that you currently have.
* Specify.


10. Do you have any hearing loss?
* Yes No

11. If “yes,” please indicate the degree of hearing loss.



Section Three: Travel Skills

12. Have you had orientation and mobility training (cane training)?
* Currently receiving training Received training in the past No

13. If you received orientation and mobility training (cane training) within five years, please provide the following information for the agency that trained you.

Date completed training

Name of agency

City

State

Contact person

Phone

14. How often do you travel without assistance, negotiating routes with street crossings?
* Daily Often Occasionally Rarely Never

15. How would you rate your confidence as an independent traveler?
* High Moderate Low


Section Four: Guide Dog Information

16. Have you previously used a guide dog?
* Yes No

If “yes,” please continue. If “no,” then skip to Question # 21.

17. How many guide dogs have you had?
Please specify.


18. When did you receive your first guide dog?
Please specify.


19. When did you last use a guide dog?
Please specify.


20. At which guide dog school(s) did you receive guide dog training?
Please give name


21. Have you ever applied to another school for a guide dog?
Yes No

22. Please list those schools and the status of application. (For status, please indicate if the application was approved, declined, or is still pending.)


23. Have you ever been rejected by another guide dog school?
Yes No

24. If “yes,” please indicate which school(s).
Please specify.


25. Are you able to adequately maintain a guide dog? (Food costs approximately $35 per month; veterinary care is extra.)
Yes No

Once our Consumer Services Department has received this completed application, we will mail you an Information Release Form to sign and return. In addition, the Guide Dog Foundation requires applicants for a guide dog to submit three personal references, a reference from the agency that provided you with Orientation and Mobility services, a letter from your ophthalmologist, a medical clearance form from your physician. Information on these letters will be sent to you once we receive this application.

By clicking the “Submit” button, I hereby declare that the above statements have been truthfully answered to the best of knowledge. I understand that the Guide Dog Foundation may need further information to process my application, and that completing this application places neither the Guide Dog Foundation nor myself under any obligation.

* Name of Applicant (Please type your full name; this will serve as your signature)


* Today’s Date