Personal Reference Step 1 of 3 33% You were recommended as a personal reference as part of an application to our guide dog mobility training program at Guide Dogs of America. To help in our evaluation, we are seeking information about this applicant’s independence in daily activities and travel skills. Your thoughtful responses will be treated in a confidential manner. If you wish to contact us by telephone, please call (818) 833-6428.You were recommended as a personal reference as part of an application to our guide dog mobility training program at Guide Dogs of America. To help in our evaluation, we are seeking information about this applicant’s independence in daily activities and travel skills. Your thoughtful responses will be treated in a confidential manner. If you wish to contact us by telephone, please call (818) 833-6428.Applicant InformationApplicant Name Applicant's First Name Applicant's Last Name Reference InformationReference Name Reference First Name Reference Last Name EmailYour Email Address (you will receive an email confirmation upon submission) Reference Address Reference Street Address Reference Address Line 2 Reference City Reference State / Province Reference ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Reference Country PersonalHow long have you know the applicant?*What is the nature of your relationship (i.e. friend, neighbor)?*Do you feel the applicant has adjusted to being blind?*Do you feel applicant is able to handle stress in a positive manner?*Do you feel the applicant makes sound judgments?*Does the applicant participate well in social gatherings?*Is the applicant able to communicate effectively with others?*Does the applicant keep the home maintained in a neat and orderly fashion?*Does the applicant get out on a daily basis?*Does the applicant have sufficient income to care for a guide dog (approximately $120.00/month)?*Does the applicant have pets currently or in the past?*Does the applicant care for pets appropriately?*Do you know if the applicant has a guide dogs currently or had one in the past?*COMMENTS:* TravelDoes the applicant use a long mobility cane when walking?*Have you known/observed the applicant to travel to destinations independently? Examples:*Type of tranist used (car, bus, shuttle, train):*Does the applicant cross major lighted intersections independently?*COMMENTS:* Health & IndependenceIs the applicant able to manage medications independently?*Is the applicant able to manage medical conditions independently?*Does the applicant have sufficient stamina to walk for 1⁄2 hour?*Does the applicant prepare their own meals?*To the best of your knowledge, does the applicant overindulge or abuse alcohol or drugs? If so, please explain:*Do you feel the applicant would benefit from the use of a dog? Please explain:*COMMENTS:*NameThis field is for validation purposes and should be left unchanged.
