Student Application

Personal Information

Title
---Mr.Ms.MissMrs.Dr.Rev. *

First Name
*

Middle Name

Last Name
*

Nickname

Other Name you are known by

Email
*

Primary Phone
   ---HomeWorkCellOther *

Secondary Phone
   ---HomeWorkCellOther *

Other Phone
   ---HomeWorkCellOther

Street Address 1
*

Street Address 2

City
*

State/Province
*

Zip/Postal code
*

Mailing Address (if different)

City

State/Province

Zip/Postal code

Birth Date
---010203040506070809101112 /   ---01020304050607080910111213141516171819202122232425262728293031 /   ---191219131914191519161917191819191920192119221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998 *

Gender   ---FemaleMale *

Height    
Weight   

Marital Status   ---SingleMarriedPartneredDivorcedWidowed

Spouse's Name

Living Situation

How many people live with you?

Adults   

Children (please note ages):

Are there any pets in the home?   ---YesNo *
Please describe:

Residence   ---HouseApt.Condo/TownhomeMobile HomeRoomAssisted Living

Is your environment:   ---RuralResidentialUrbanOther
If Other, please explain:

Occupation & Activities

Currently employed?   ---YesNo *
Current occupation

Current employer

Current supervisor

Previous occupations:

Volunteer activities:

Hobbies:

Outdoor Activities:

General Information

What are your plans for the future?

Have you ever been convicted of a felony?   ---YesNo *
If yes, please provide details:

How did you hear about Guide Dogs of America?

Does anyone (family member, employer, landlord) object to your getting a guide dog?   ---YesNo *

Guide Dogs of America grants full ownership of the guide dogs upon completion of the program. Can you provide the necessary food, medical and general care necessary for your dog (costs can be $1000 per year or more)?
---YesNo *

If not employed, please state means of support.

Education

Educational level completed   ---ElementaryHigh schoolSome collegeAdvanced degree

School for the Blind (please specify)

Special Training (please specify)

Are you a Veteran?   ---YesNo *

Are you fluent in English?   ---YesNo *

Preliminary Medical

Cause of Blindness:
*

When were you declared legally blind?

Vision loss in:
Left?    Right?   

Any residual vision?   ---Tunnel visionPeripheral visionFragmented vision

Please describe any physical or medical limitations

Do you have any hearing loss?    ---YesNo *

If so, please describe:

Any history of:

Other?

Please list all routine medication that you take:

Allergies to medications?

Allergies to food?

Emergency medication?

Special dietary needs?

Travel Skills

Have you had Orientation & Mobility Training?   ---YesNo *
Date received?   
By agency?

Have you had Rehabilitation & Living Skills Training?   ---YesNo *
Date received?   
By agency?

Are you an experienced, independent traveler?   ---YesNo *

Primary type of mobility?   ---Travel without assistanceSighted guideMobility caneGuide dog

Do you know your home area?   ---YesNo *

Please describe your daily travel:

How many blocks do you walk daily?   

Do you cross intersections unassisted?   ---YesNo *

Have you previously used a guide dog for mobility or attended a class that you did not complete?   ---YesNo *

If so, please give details for each dog or school experience. If you need more space, please use the "Additional Information" field.

Additional Information:

Medical References

In the course of your application with Guide Dogs of America, it may be necessary to contact your doctors for further information. Please fill in the names, addresses and phone numbers of the medical professional from which you receive services. If you need more space, please use the Additional Information field.

Primary Physician
Name:
*
Address:
*
City:     
State:    Zip:   
Phone:  *

Opthalmologist
Name:

Address:

City:     
State:    Zip:   
Phone: 

Other Medical Professionals (such as Neurologist, Mental Health Professional)

Profession:

Name:

Address:

City:     
State:    Zip:   
Phone: 

Profession:

Name:

Address:

City:     
State:    Zip:   
Phone: 

Medical Insurance Information

Carrier:
*

Policy/ I.D. Number:
*

Additional Information:

Rehabilitation, Mobility and Employment References

So we can provide you with the best possible service, we request the following references to obtain additional information. These people will be contacted regarding your particular living and working needs. Please leave spaces blank if you are not in contact with any of the following service professionals.

Orientation & Mobility Instructor
Name:

Address:

City:     
State:    Zip:   
Phone: 

Blindness Services Counselor
Name:

Address:

City:     
State:    Zip:   
Phone: 

Employer or Volunteer Activity
Name:

Address:

City:     
State:    Zip:   
Phone: 

Personal References

Please list the names and contact information for three people (other than relatives or blindness services professionals)
This section must be completed

Name 1:
*
Street Address:
*
City:     
State:    Zip:   
Phone:  *
Email:    *

Name 2:
*
Street Address:
*
City:     
State:    Zip:   
Phone:  *
Email:    *

Name 3:
*
Street Address:
*
City:     
State:    Zip:   
Phone:  *
Email:    *

Emergency Contacts

Please provide the name of two people to notify in case of emergency

Name 1:

Phone number:

Email:

Name 2:

Phone number:

Email:

Guide Dogs of America, does not discriminate on the basis of age, gender, race, religion, national or ethnic origin, marital status or any other factor prohibited under local, state of federal laws.

Guide Dogs of America staff will assess the information submitted, and will contact you regarding your status. At that time, additional information will be required to continue the admissions process, such as doctors' and mobility reports, an instructor evaluation or a video.

I understand that completing this form places neither me nor Guide Dogs of America under any obligation, but assists Guide Dogs of America in the determination of my eligibility for training. I also know that sometimes it is necessary to decline an application, and that Guide Dogs of America reserves the right to do so without giving any explanation. If my application is accepted, I agree to complete the course of instruction as prescribed by the California State Law and to abide by the rules and regulations of Guide Dogs of America in the use and care of my Guide Dog.

I declare that the information provided in this application is true to the best of my knowledge.

I agree. *

Please provide the full name of applicant. This will serve as your signature:
*

Thank you for your application to train at Guide Dogs of America. We look forward to getting to know you, and working with you in the future.

* - Required