Application for O&M Immersion Program

Contact Information

First Name (Required)

Middle Name

Last Name (Required)

Date of Birth (Required)

Street Address (Required)

Street Address 2

City (Required)

State

Zip Code

Country (Required)

Is this your mailing address as well?

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)

Email (Required)

General Information

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

If yes please list dates.

Are you a veteran?

Have you ever had an alcohol or substance abuse problem?

Have you ever been convicted of a felony?

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

Personal and Health Information

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

Legal blindness is defined as visual acuity of 20/200 or worse or a field restriction of 20 degrees or less in both eyes.

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.

Rehabilitation Training

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

If yes, please indicate when your training was completed.

Within the last year1-5 years agoMore than 5 years ago

Travel Practices

Do you currently use mobility aid?

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

CaneGuide DogSighted GuideOther

If other, please specify.

Have you previously had a guide dog?

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

Leader Dogs

Pilot Dogs

Guiding Eyes

Other

Seeing Eyes

Please list dates of service.

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

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

Destinations

Although it is not required that you have established routes for the Immersion Program, Please list any routes that you do travel independently here for our reference. 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

Optional Question Used For Statistical Purposes

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.

Next Step

Please select the preferred way to receive information:

The next step will be a phone consultation with a member of our team. Estimated time to complete the consultation is approximately 60 minutes. Please provide the best date and time to reach you for a phone consultation.

Immersion Program Understanding

The O&M Immersion is a six-day residential training program that requires sustained cognitive, physical, emotional. and social functioning. Clients must be reasonably independent and demonstrate average tolerance to dormitory life. Do you think you can cope with the stress of being in a new group environment along with learning and applying O&M skills for this time period?

I understand the Immersion Program

___________________________________________________ I understand that completing this form places neither me nor Guide Dogs for the Blind under any obligation, but assists Guide Dogs for the Blind in determining my eligibility for the O&M Immersion.

Guide Dogs for the Blind, Inc. does not discriminate against any applicant for admission to the Guide Dog 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. I hereby declare that the information given above is accurate to the best of my knowledge.

I agree

___________________________________________________ By submitting this application I understand that my application content, including professional reports, will be reviewed by the O&M Immersion Program staff and Admissions Review Committee. If accepted to train, the pertinent details from my GDB file will be shared with the partner agency and O&M specialist I am assigned to. This information is considered confidential and will not be shared outside of these parameters without my express written consent.

I agree

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.

African American	Asian	Caucasian
Native American	Latino/Hispanic	Other
Decline to State