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Careers & Canine Connections Application

Included in this Application

Participant application (Page 1)
Transportation Form (Page 2)
Proof of Medical Insurance (Page 3)
GDB Publicity Release and Release of Liability (Page 4)
Consent for Release of Information Form (Page 5)
Permission to Provide Emergency Care (Page 6)
e-Signature (Page 7)

Required Supporting Documents

The essay questions, as outlined below.
A current photo of the applicant
Copy of insurance card
Physician's Report to be completed by the applicants Primary Care Physician (Download via the link below if you haven't already done so from our website)
Download Physician's Report

Essay Questions

Please provide answers to the following essay questions. Each response should be approximately two paragraphs (300–400 words) in length. This is intended as a guideline to help ensure that your answers reflect thoughtful consideration and provide sufficient detail to demonstrate your perspective, experience, and reasoning. If your response naturally extends beyond this length, that is perfectly fine; please focus on fully addressing the question rather than limiting your response to a specific word count.

1. Reflect on your interests, strengths, or future career ideas. How do you imagine your blindness or low vision shaping your approach to employment, self-advocacy, and professional growth?

2. Describe your current approach to travel (with a cane, human guide, or prior guide dog experience). What interests you about exploring guide dog travel, and what questions or hopes do you have about a guide dog partnership?

Participant Application

Participant's Information

Prefix

First Name (Required)

Middle Name

Last Name (Required)

Email (Required)

Address Information

Street Address (Required)

City (Required)

State (Required)

Country (Required)

Zip Code (Required)

Is this your mailing address as well? (Required)

Mailing Address

City

State

Country

Zip Code

Contact Information

Preferred Phone (Required)

Home Phone (area code first) (Required)

Work Phone (area code first) (Required)

Mobile Phone (area code first) (Required)

Other Phone (area code first) (Required)

Preferred method of correspondence (Required)

Date of Birth MM/DD/YYYY (Required)

All applicants must be between the ages of 18 and 24 to apply.

Gender

Pronoun (optional)

Ethnicity (optional)

Primary Language Spoken

Application

Emergency Contacts:

#1 Emergency Contact Name (Required)

#1 Emergency Contact Email (Required)

#1 Emergency Contact Phone (Required)

#1 Emergency Contact Relationship (Required)

#2 Emergency Contact Name

#2 Emergency Contact Email

#2 Emergency Contact Phone

#2 Emergency Contact Relationship

Personal and Health Information:

Has the participant attended any programs through Guide Dogs for the Blind or the American Printing House Career Connect program?

If Yes what Program(s)/year(s)

Year participant declared legally blind?

Cause of visual impairment?

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

If partially sighted, describe the applicant's functional vision:

Right eye:

Left eye:

Does the participant have physical limitations such as neuropathy or problems with balance?

If yes please describe:

Does the participant have any cognitive, emotional, behavioral or psychological diagnosis?

If yes please describe:

Does the participant see a mental health professional for emotional or psychological diagnosis?

If yes, how long has the participant been under their care?

Does the participant have a seizure disorder?

If yes, date of last seizure

Does the participant have hearing loss?

Left ear:

Right ear:

Does the participant require assistance with their medications and/or medical condition?

If yes please describe:

Please describe how the participant might react to the following:

Unexpected change:

Loud noises:

Not having a consistent routine:

Can the participant participate in walks up to an hour in length?

Can the participant swim independently in a pool of 3-foot depth?

Can the participant swim independently in a pool of 6-foot depth?

Can the participant swim independently without a flotation device?

Does the participant have any food allergies?

If yes, please list specific foods

Is the participant on a special diet?

If yes, please indicate any dietary restrictions/needs:

Is the participant currently using a mobility aid?

Please indicate what kind of mobility aid currently using.

If other, please specify.

Has the participant ever had an alcohol or substance abuse problem?

Has the participant ever been convicted of a felony (Indictable offense)?

Is there anything else that would be helpful for us to know about the participant? (please describe)

Other

How does the applicant prefer to receive printed material?

Applicant’s T-shirt size (Shirts are unisex style):

How did the applicant hear about the Careers & Canine Connections program?

Supporting Documents

1) The essay questions

2) A recent picture of the applicant

Please upload the essay questions here: (Required)

Please upload the picture of applicant here: (Required)

Acknowledgment

I understand that completing this form places neither myself nor Guide Dogs for the Blind under any obligation for services. This information is only intended to assist Guide Dogs for the Blind in determining my eligibility for the Careers & Canine Connections program.

Participant's Name (Required)

By checking YES, I acknowledge that the above information is true and that any falsified information may result in denial of participation.

Yes (Required)

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Careers & Canine Connections

Transportation Form

How will the applicant arrive to Hull Park Foundation
for Camp GDB.

Out of area, will be arriving by Plane (Guide Dogs for the Blind will provide transportation from the airport to the Hull Park Foundation.

Out of area, will be arriving by Plane but we will provide transportation to the Hull Park Foundation.

I live locally and will provide transportation to the Hull Park Foundation.

How will the applicant depart from Hull Park Foundation at the end of Camp GDB.

Out of area, will be departing by Plane (Guide Dogs for the Blind will provide transportation to the airport from the Hull Park Foundation.

Out of area, will be departing by Plane but we will provide transportation from the Hull Park Foundation to the airport.

I live locally and will provide transportation from the Hull Park Foundation.

Please provide the name and contact information of the person(s) who will be dropping off and/or picking up your child from the Hull Park Foundation.

Drop off (first day at 2:00pm):

Name

Relationship

Phone Number:

Pick up (last day at 10:00am):

Name

Relationship

Phone Number:

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Proof of Medical Insurance

Medical Insurance

Guide Dogs for the Blind requires that all participants are insured and can show proof of medical insurance. If your child is uninsured, we require that you purchase traveler’s insurance for the duration your child will be at camp, and we have provided two resources for this below.

Name of insured

Primary Care Physician

Physicions Number

Name of insurance carrier:

Membership Number:

Expiration date (if no date leave blank):

Please include:

A copy of you medical insurance card below

Uninsured camper Resources:

Travel Guard

800-826-5248

www.travelguard.com

Word Nomads

www.worldnomads.com

Also, if you have a VIAS Credit Card it may offer travelers insurance at a reduced rate.

Supporting Documents

1) Please attach a copy of your medical insurance card or proof of their traveler's insurance

Please upload proof of insurance here: (Required)

Acknowledgment

By checking YES, I acknowledge that the above information is true and that any falsified information may result in denial of participation.

Yes (Required)

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Careers & Canine Connections Media, Promotion and Personal Information Release Form

Release of Liability Form

Publicity Release:

GUIDE DOGS FOR THE BLIND may wish to use various multimedia files (e.g., photography, audio/video recordings) and general information about participants in our programs for publicity and/or marketing purposes. These files may be used in any and all promotional media, including but not limited to: newsletters, brochures, website, blog, fundraising materials, social media channels, press coverage, promotional videos, public service announcements, etc. Also, please be advised that at GDB events (either on our campuses or hosted elsewhere), photography, audio/video recording, and live streaming may occur. By attending a GDB event, you consent to such recording media and its release, publication, exhibition, or reproduction. Thank you!

The Publicity Release options are as follows:
Full Permission For Publicity: The undersigned does hereby give permission to use their likeness for marketing or publicity purposes, or to otherwise promote GUIDE DOGS FOR THE BLIND to the public from the date signed and in perpetuity. Minors must have a parent or guardian’s signature.
Denial of Permission For Publicity: I do not want my likeness used for marketing or publicity purposes by GUIDE DOGS FOR THE BLIND.

Please Select One of the Publicity Release options (Required)

Release of Liabilty

In consideration of the undersigned being accepted as a student, and in further consideration of the training, use of the facilities, and other benefits the undersigned receives from Guide Dogs for the Blind, Inc. (“GDB”), the undersigned does hereby agree, among other things, that he or she shall hold harmless GUIDE DOGS, its directors, employees, officers, representatives, heirs, executors, administrators, agents and assigns from liability for any injury, damage, sickness and/or medical expense or eventuality that may occur or arise as a result of the undersigned’s training, attendance at the school and use of the facilities, except as a result of negligence on the part of said GDB, the undersigned does hereby release, indemnify and hold GDB free and harmless from any and all liability, claims, damages, losses or expenses, including counsel fees and costs, arising as a result of the undersigned’s training and/or attendance at the GDB school and use of the facilities.

The undersigned understands that a safe is provided by GDB for student’s valuables, and therefore will not hold said GDB liable for the loss of monies, jewelry, records and/or other personal articles of value that he or she may choose to retain in his or her possession.

By checking YES, I accept the terms to this release of liability

Yes (Required)

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Authorization for Use or Disclosure of Medical and Other Information

Consent Form

Please complete the following consent form. This form allows Guide Dogs for the Blind to contact your physician, Orientation & Mobility instructor and mental health professional (if applicable) for information that will help us complete your Camp GDB application. It is not necessary to bring this form to your providers. We will send them the necessary forms if you provide us with their complete mailing addresses. If you do not have a physician you see regularly, please leave that section blank and we will send the form directly to you to take to your doctor.

A. Explanation: This authorization for use or disclosure of medical or rehabilitation information is being requested from you to comply with the terms of the Confidentiality of Medical Information Act of 1981, California Civil Code Section 56, et seq.

B. Authorization: I hereby authorize the below listed providers, to furnish to Guide Dogs for the Blind, Inc. and its authorized representatives, any medical records, which include information pertaining to medical history, mental or physical condition, services rendered, and/or treatment for the purpose of attending the Careers & Canine Connections program. This authorization extends to all information requested in the required Physician’s Report, the Mental Health Professional’s Report and the Orientation and Mobility Instructor Report

I understand that authorizing the disclosure of my medical information is voluntary. I can refuse to sign this authorization. I further understand that I have the right to inspect and copy the information disclosed as a result of this authorization. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure, which may or may not be protected by federal or state confidentiality rules. If I have any questions about the disclosure or use of this information, I may contact the Admissions Manager at Guide Dogs for the Blind at 1 800 295 4050.

C. Uses: Guide Dogs may use the medical records and information authorized: to assist in the determination of eligibility for the Careers & Canine Connections program to assist Guide Dogs in providing the participant with medical assistance during the program; and for any other legally permissible reason deemed necessary by Guide Dogs.

Access to medical and mental health records will be restricted to Guide Dogs’ staff involved in the application, assessment, selection and care of applicants and participants. This group consists of: Nursing and Admissions /Graduate Services staff,. Members of the GDB IT staff will also have access to this information.

D. Duration: This authorization shall become effective immediately and shall remain in effect for two years after the date signed below.

E. Restrictions: I understand that Guide Dogs may not further use or disclose the medical information except as authorized herein unless another authorization is obtained from the applicant or unless such use or disclosure is specifically required or permitted by law.

F. Additional Copy: I further understand that I have a right to receive a copy of this authorization upon my request.

Authorized List of Providers and Their Mailing Addresses

Primary Physician (medical doctor)

(Please do not list your ophthalmologist or optometrist)

Name of Physician:

Name of Medical Center:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Mental Health Professional (if applicable)

Name of Counselor:

Name of Office:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Orientation and Mobility Specialist (COMS)

Name of Instructor:

Name of Agency:

Street Address:

City, State Zip:

Phone Number:

Fax Number:

Email Address:

Supporting Documents

1) Please attach a copy of the Physicians Report here.

Please upload Physicians Report here: (Required)

Name: (Required)

Date: (Required)

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Permission To Provide Necessary

Emergency Care

Permission to Provide Necessary Emergency Care:

I hereby give permission to Guide Dogs for the Blind, Inc., to provide routine health care and seek emergency medical treatment if indicated, and give permission to Guide Dogs for the Blind, Inc., staff to communicate with emergency personnel and physicians if necessary.

Applicant's Name (Required)

Date: (Required)

Emergency Contact Phone Number (Required)

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e-Signature

Application Package e-Signature

I, [Full Name] (Required)

acknowledge that I have read and understand the program information, including the programs policies, procedures, and activities.

I understand that participation in programs activities involves inherent risks, and I assume these risks on behalf of myself.

I hereby give permission to Guide Dogs for the Blind, to provide routine health care and seek emergency medical treatment if indicated, and give permission to Guide Dogs for the Blind, staff to communicate with emergency personnel and physicians if necessary.

I have provided accurate and complete information on this application, including my medical history and any special needs. I agree to inform the GDB immediately of any changes to this information.

Date (Required)

Name(Required)