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Guide Dog Program Application

Your Information

Gender

Prefix

First Name (Required)

Middle Name

Last Name (Required)

Date of Birth MM/DD/YYYY (Required)

Email (Required)

Address Information

Street Address (Required)

Street Address 2

City (Required)

State (Required)

Country (Required)

Zip Code (Required)

Is this your mailing address as well? (Required)

Mailing Address

Street Address

Address 2

City

State

Zip Code

Country

Contact Information

Preferred Phone (Required)

Home Phone (area code first) (Required)

Work Phone (area code first) (Required)

Cell Phone (area code first) (Required)

Application

Have you ever applied to Guide Dogs for the Blind before? (Required)

Have you worked with any other dog guides before? (Required)

If you have worked with a dog guide before, from which organization did you receive it? (check all that apply)

Guide Dogs for the Blind

The Seeing Eye

The Guide Dog Foundation

Leader Dogs

Guide Dogs of America

Guiding Eyes

Pilot Dogs

Other

If yes please list dates of service.

Are you a veteran?

Have you ever had an alcohol or substance abuse problem?

Have you ever been convicted of a felony (indictable offense)?

Guide Dogs for the Blind will consider applications from individuals with felony convictions on a case by case basis.

Year in which you were declared legally blind. (Required)

What is the cause of your blindness?

If your cause of blindness is not in the list above, please describe.

Aside from blindness, please list any other physical disabilities.

Have you received Orientation & Mobility (O&M) training?

If yes, please indicate when your training was completed.

Do you currently use a mobility aid.

If yes, please indicate what type of mobility aid you use:

If other, please specify.

Do you cross the street without the assistance of other people?

On average, how many blocks do you walk independently every day?

Destinations

During a home visit you will be required to demonstrate the ability to travel independently for 1/2 to 1 mile, including street crossings. Please list up to 3 destinations that you travel to independently on a regular basis. If you have addresses for the destinations, Please include that information.

For example, Home to Joe's Cafe at 1000 A Street.

Destination 1

Destination 2

Destination 3

During the phone consultation, please be prepared to discuss these routes, including the types of intersections along the way, as well as how you determine when it is safe to cross the street.

Ethnic Background (optional)

Guide Dogs for the Blind, Inc. does not discriminate against any applicant for admission to our program based upon race, religion, color, national origin, ancestry, age, marital status, gender, or any other factor prohibited under local, state or federal laws. Any applicant denied admission may subsequently reapply and be reconsidered without prejudice.

Phone Consultation

The next step will be a phone consultation with a member of our Admissions Department.

Prior to the phone consultation, please review the content of the mailed Application Packet in the Guide Dog Program and links section of our website, in particular the Guide Dog Self Screening and the Sample Guide Dog User Contract. Estimated time needed to complete the consultation is approximately 45 minutes.

I would like to receive correspondence via (Required):

Consent Form Information

As part of the application process you will be asked to fill out a consent form which will be sent separately. This form allows Guide Dogs for the Blind, Inc. to contact your professional references (physician, ophthalmologist, mental health professional, orientation and mobility instructor, rehabilitation professional and other guide dog schools) for information that will help us complete your application.

Public Domain Internet Search

As part of the standard screening process, Guide Dogs for the Blind will conduct a public domain internet search on all program applicants. Guide Dogs for the Blind will not request access to non-public social media. No information gathered during this search of publicly available data will be shared with any other organization or provider.

Acknowledgement

I hereby declare that the information given above is accurate to the best of my knowledge.

I Agree

(Required)

By submitting this form, you acknowledge that Guide Dogs for the Blind may email you about this program, our services and organization. You may opt out or manage your email preferences at any time.

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Contact Information

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