Home Street Address 1 *Required
Home Street Address 2
Zip code/Postal Code *Required
Country (Click first letter for shortcut - leave blank for United States)
Home Phone (Include area code) *Required
Date of Birth (MM/DD/YYYY) *Required
For statistical purposes, what is your ethnic background?
Are you legally blind?
Year of vision loss (Enter four digit year) *Required
Cause of blindness *Required
Amount of vision *Required
Do you have hearing loss? If so, what degree of loss?
Other physical disabilities
Please describe how your disability affects your life, and your current level of independence.
Are you a veteran? *Required
If yes, what branch of service?
If yes, what campaign did you serve?
If yes, were you honorably discharged?
If discharged, please provide a copy of your DD-214 (Member-4) by sending a copy to: Janice2@vetdogs.org, Fax: 631-930-9075 or mail: America’s VetDogs Consumer Services, 371 E. Jericho Tpke. Smithtown, NY 11787.
Are you currently employed? If yes, what is your present occupation? *Required
Have you ever had a drug or alcohol abuse problem? * Required
Have you ever been convicted of a felony? *Required
If yes, please provide details
Are you currently seeing any of the following specialists? *Required (Please check all that apply.)
Have you had mobility instruction? *Required
If so, when? (Enter four digit year)
What type of mobility aid do you use primarily? *Required
Do you cross streets without assistance from other people? *Required
Do you currently have, or have you had a guide dog before? *Required
If yes, from where?
On average, how many blocks do you independently walk each day?
Please list up to 3 destinations that you independently walk on a regular basis. Please list the mailing address if available. *Required
Determining factor in your decision to apply? *Required
Above statements have been truthfully answered *Required
CONSENT TO RELEASE - Use your "Arrow" keys to navigate and read the information below. This Consent section of the form must be signed below.
This authorization shall become effective immediately and shall remain in effect for a three-year period from the date it was signed. This is to authorize any physician, hospital, firm, organization or person to furnish to the Guide Dog Foundation for the Blind, Inc. and America's VetDogs - the Veteran's K-9 Corps (hereinafter referred to as "GDF & AVD"), all information, material or opinions that may be requested by GDF & AVD concerning me. GDF & AVD are further authorized to copy any records pertaining to me. I hereby waive any privilege I have to said information to GDF & AVD, and agree to hold GDF & AVD blameless from any claims as a result of the sharing of information related to me.
The Information received by GDF & AVD, will only be used to evaluate my application for a guide or service dog and training in the use thereof.
I understand that any information provided to GDF & AVD will remain confidential.
I understand that my failure to disclose any medical or personal information that pertains to my ability to work with an assistance dog may result in the denial of my application or termination of training.
By clicking “Submit” with my name typed below, I agree to submit this application, which includes the Foundation Code of Conduct and the Consent to Release form, by electronic means and adopt such process with the intent to sign this form.
Please type your full name and this will serve as your signature.
Applicant’s name / parent guardian if applicable *Required (type full name in box)
Date (MM/DD/YYYY) *Required
If it is determined that you are qualified to participate in our guide dog training program, you will be invited to continue with Part Two of the application, which includes a medical report, O&M report, ophthalmology report, and application video. Would you prefer these forms be sent to you by mail or electronically?