Application for Guide Dog Mobility Training

* Name:

* Address:

* City:

* State: * ZIP Code:

* Home Phone:

Work Phone:

Cell Phone:

* Email:

* Date of Birth: * Age: * Gender: MaleFemale

Race/Ethnic Origin:

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: Less than 6 Months6-12 Months1-5 YearsMore than 5 Years

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

If you are anticipating a lifestyle change, please describe:

Do you routinely travel independently?: NoYes

Do you consider yourself a confident traveler?: NoYes

Current method of travel?: CaneSighted GuideGuide DogOther

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: AnyLabrador RetrieverGolden RetrieverStandard Poodle

If you have a breed preference, please explain why?

Have you ever attended guide dog school?: NoYes

If yes, please list:

Do you now or ever had dogs as pets? YesNo

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

Please list any other pets:

Highest level of education: ElementaryHigh SchoolSome CollegeCollege GraduatePost Graduate

Please list any special degrees or training:

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

Are you a US veteran? NoYes

If yes, which service?

Are you currently employed? NoYes

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: $5,000 - $10,000$10,000 - $20,000$20,000 - $30,000$30,000 - $40,000Above $40,000

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

* Name:

* Address:

* City:

* State: * ZIP Code:

* Home Phone:

Work Phone:

* Cell Phone:

Relationship:

Name:

Address:

City:

State: ZIP Code:

Home Phone:

Work Phone:

Cell Phone:

Relationship:

Height: Weight:

Are you legally blind? YesNo

If so, when did you become legally blind?

Cause of blindness:

Please describe your residual vision:

Do you have a hearing impairment? YesNo

Do you wear hearing aids? YesNo

Do have any physical limitations or special needs? YesNo

If yes, please describe:

Have you ever had seizures? NoYes

If so, when was the last seizure?

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

Are you insulin dependant? NoYes

What diet do you follow? Diet Discepline: StrictCasual

Please list your dietary needs:

Please list any surgeries:

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

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):

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):

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

Comments:

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

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? NoYes

Would you consider it? NoYes

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

Was it an in-residence program? NoYes

If yes, please give location:

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:

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: