First Time Applicant Form

Apply for Guiding Eyes training online by using the form below. Please note that these applications must be completed in full and submitted. When working online you are not able to save unfinished applications.

Note to first time applicants: We cannot process your application without receiving the signed Release Form. If we don’t receive the signed form within 3 weeks of receiving your application, your file will become dormant and no further action will be taken on it.

1. 1. Title: Select... Mr. Mrs. Ms. Miss Dr.
2. 2. First Name:(required)
3. 3. Middle Name:
4. 4. Last Name:(required)
5. 5. Suffix: Select... Jr. Sr. II III IV V
6. 6. Email:(valid email required)
7. 7. Street 1:(required)
8. 8. Street 2:
9. 9. City:(required)
10. 10. State:(required)
11. 11. Zip/Postal Code:(required)
12. 12. Country:
13. 13. Phone:(required)
14. 14. Occupation:
15. Date of Birth
16. 15. Month: Month... January February March April May June July August September October November December
17. 16. Day: Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
18. 17. Year:
19. 18. Yes, I would like to receive e-mail from Guiding Eyes for the Blind.
20. 19. Work Phone:
21. 20. Cell Phone:
22. 21. Marital Status
23. Married Single Divorced Widowed
24. 22. Cause of vision loss:(required)
25. 23. Date of onset
26. 24. Distance/Central Vision Right Eye:
27. 25. Distance/Central Vision Left Eye:
28. 26. Peripheral/Field Vision Right Eye:
29. 27. Peripheral/Field Vision Left Eye:
30. 28. General Health Please select a response... Poor Fair Good Excellent (required)
31. 29. List physical problems, if any:(required)
32. 30. Medical Insurance Company:(required)
33. 31. Medical Insurance Policy Number:(required)
34. 32. Emergency Contact Name:(required)
35. 33. Emergency Contact Home Phone:(required)
36. 34. Emergency Contact Relationship:(required)
37. 35. Emergency Contact Work Phone:
38. 36. Who/What influenced you most in deciding to apply to Guiding Eyes for the Blind?
39. Correspondence Preferences
40. 37. First Choice: Please select a response... Print Large Print Email Braille (required)
41. 38. Second Choice: Please select a response... Print Large Print Email Braille
42. 39. Third Choice: Please select a response... Print Large Print Email Braille
43. Professional References
    
    The Admissions Department will contact all Professional and Personal References. Please provide complete names and addresses, including zip codes.
44. Orientation and Mobility Training
    
    If you have had Orientation and Mobility training within the past 5 years.
45. 40. Name of Agency:
46. 41. Agency Phone:
47. 42. Agency Fax:
48. 43. Agency Address:
49. 44. Agency City:
50. 45. Agency State:
51. 46. Agency Zip:
52. 47. Instructor's Name:
53. 48. Dates of Instruction:
54. Rehabilitation Services
    
    If you have received Rehabilitation services within the last 5 year.:
55. 49. Name of Agency:
56. 50. Agency Phone:
57. 51. Agency Fax:
58. 52. Agency Address:
59. 53. Agency City:
60. 54. Agency State:
61. 55. Agency Zip:
62. 56. Counselor's Name:
63. 57. Dates of Instruction:
64. Personal References
    
    Please inform your references that we will be contacting them. The sooner they respond to our request for information, the sooner your file will be complete and ready for review by the Admissions Committee.
65. List three personal references (OTHER THAN FAMILY OR PROFESSIONAL REFERENCES):
66. Reference 1
67. 58. Full Name:(required)
68. 59. Street:(required)
69. 60. City:(required)
70. 61. State:(required)
71. 62. Zip/Postal Code:(required)
72. 63. Email:(valid email required)
73. Reference 2
74. 64. Full Name:(required)
75. 65. Street:(required)
76. 66. City:(required)
77. 67. State:(required)
78. 68. Zip/Postal Code:(required)
79. 69. Email:(valid email required)
80. Reference 3
81. 70. Full Name:(required)
82. 71. Street:(required)
83. 72. City:(required)
84. 73. State:(required)
85. 74. Zip/Postal Code:(required)
86. 75. Email:(valid email required)
87. Other Guide Dog Schools
    
    List any guide dog schools you have attended:
88. 76. School Name:
89. 77. Dates Attended:
90. 78. Graduated?
91. Yes No
92. 79. School Name:
93. 80. Dates Attended:
94. 81. Graduated?
95. Yes No
96. 82. School Name:
97. 83. Dates Attended:
98. 84. Graduated?
99. Yes No
100. 85. Your name when you attended the school(s), if different.

 

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