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Every seven minutes someone in America becomes legally blind or visually impaired.

Application for Guide Dog Mobility Training

An * indicates a required field.

Applicant Information

* Name:

* Address:

* City:

* State: * ZIP Code:

* Home Phone:

Work Phone:

Cell Phone:

* Email:

* Date of Birth: * Age: * Gender:

Race/Ethnic Origin:


Applicant Lifestyle

Name of Spouse/Domestic Partner:

Number of Children: Children's Ages (if any):

Name of Person you reside with:

Please describe your house or apartment:

Please describe your neighborhood:

How long have you lived at your residence:

Do you anticipate a move or lifestyle change within the next year?:

If you are anticipating a lifestyle change, please describe:

Do you routinely travel independently?:

Do you consider yourself a confident traveler?:

Current method of travel?:

Please describe the areas you frequent:

What obstacles/challenges do you encounter in the areas you frequent?

Do you encounter stray or loose dogs, agressive dogs (restricted or behind fences), small animals (squirrels, rabbits, etc.)?

Why do you desire a guide dog?

Breed preference:

If you have a breed preference, please explain why?

Have you ever attended guide dog school?:

If yes, please list:

Guide Dog School 1

Name of School:

When did you attend?

Did you Graduate?

Reason for retirement/return:


Guide Dog School 2

Name of School:

When did you attend?

Did you Graduate?

Reason for retirement/return:


Guide Dog School 3

Name of School:

When did you attend?

Did you Graduate?

Reason for retirement/return:

Do you now or ever had dogs as pets?

If you have dogs now, what are the ages, sizes, breeds and personalities?

Please list any other pets:


Educational Background

Highest level of education:

Please list any special degrees or training:

What community organizations or activities relating to blindness are you involved with, if any?


Veterans

Are you a US veteran?

If yes, which service?


Occupation

Are you currently employed?

Occupation before blindness?

Occupation after blindness?

Current Employer:

Current Employer Address:

Supervisor's Name:

Employer Phone Number:

What are the accomodations for the dog at work?

If you are not employed, what is your present means of support?

Current Annual Income Level:

Can you support the cost of a guide dog's food and health care?


Emergency Contact 1

* Name:

* Address:

* City:

* State: * ZIP Code:

* Home Phone:

Work Phone:

* Cell Phone:

Relationship:


Emergency Contact 2

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Cell Phone:

Relationship:


General Health

Height: Weight:

Are you legally blind?

If so, when did you become legally blind?

Cause of blindness:

Please describe your residual vision:

Do you have a hearing impairment?

Do you wear hearing aids?

Do have any physical limitations or special needs?

If yes, please describe:

Have you ever had seizures?

If so, when was the last seizure?

Do you have diabetes?
If so, please have you physician complete the diabetic report.

Are you insulin dependant?

What diet do you follow? Diet Discepline:

Please list your dietary needs:

Please list any surgeries:

Do you or have you ever had a substance abuse problem?

If yes, please explain:

Please describe your rehabilitation program (list program attended, location and dates):

Comments:

Do you suffer from any of the following? (check all that apply):

Coordination
Spasticity
Reduced Stamina
Brittle Bones
Chronic Pain
Speech Impairment
Balance Problems
Limited Mobility

Muscular Weakness
Paralysis
Frequent Headaches
Memory Loss
Depression
Heightened Emotions
Heat / Cold Sensitivity
Skin Sensitivity
Deafness
Hearing Loss
Allergies If you have allergies, please list:

Other please list:

Do you use any of the follow? (check all that apply):

Assistance Dog
Low Vision Aids
Wrist Braces
Support Cane
Sighted Guide
Hearing Aid

Prosthesis
Walker
White Cane
Leg Brace
Crutch
Manual Wheelchair
Other please list:

Comments:


Personal and Professional References

Incomplete information will greatly delay the processing of your application.
Please list the names and contact information of three personal references.

Reference 1

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Email:


Reference 2

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Email:


Reference 3

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Email:


Orientation and Mobility Instructor

Please list the name and contact information of your Orientation and Mobility Instructor:

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Email:

What was the date of your last Orientation and Mobility instruction?

Have you ever had any blindfold training?

Would you consider it?

Did you attend an Orientation and Mobility program that offers Independent Living skills training?

Was it an in-residence program?

If yes, please give location:


Blind Services or Rehibilitation Counselor

Please list the name and contact information of your Blind Services or Rehibilitation Counselor:

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Email:


How did you learn about Guide Dogs of the Desert?

GDD Graduate
Name of Graduate:

Lion's Club
Club Name and Location:

Convention or Conference
Conference Name and Location:

O & M Instructor
Instructor Name:

Custom Canines
Referral Name:

Other
Please Explain:

Reason for choosing G.D.D.:

Name of person who assisted you with this form: (if applicable)

Name:

Address:

City:

State: ZIP Code:

Phone:


Agreements

1. I certify that the above information is true and correct.
* I Agree:

2. I do hereby apply to Guide Dogs of the Desert for a guide dog and for special training in the use and care of said dog, with the understanding that I will not be required to pay or promise to pay any amount of money therefore. To assist Guide Dogs of the Desert in determining whether or not I can use and care for a guide dog, I submit the above information.
* I Agree:

3. I hereby give my consent and authorization to release information from the physicians, agencies and guide dog schools listed in my application, for the purposes of determining eligibility for a guide dog training program, to assist in providing appropriate medical attention, and for any other legal purpose deemed necessary by Guide Dogs of the Desert.
* I Agree:


GDD will not sell or share your mailing information with any third parties. All medical information contained in this document is confidential and will only be shared with those that you have given us authorization to share this information with as stated on the Information Release Form.


Do you want your name to be added to the GDD mailing list?

Guide Dogs of the Desert is an equal opportunity employer and school. We consider applications for all positions and guide dog mobility training, without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status. We also support a drug free atmosphere.

Please download these additional required forms then Submit Application: Medical Info Form - Download PDF Video Interview Form - Download PDF