Southeastern Guide Dogs, Inc. : OBTAINING A GUIDE DOG : Online Application
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Online Application

The form you are about to fill out contains approximately 100 questions.
(If you have already filled out the online form and need the physicians and release forms, use this link to download the physicians PDF. Use the preceeding link only if you have already filled out the following online application.)
 
 
First name
Last name
Street address or PO box
Apartment or suite number
City
State
Zip code
Home phone
Work phone
Cell phone
E-mail address
Date of birth
Gender
male female
Height
Weight
Married
yes no
Spouse's name if married
Children
yes no
1st Child name
Child's age
Live at home?
yes no
2nd child name
Child's age
Live at home
yes no
3rd child name
Child's age
Live at home
yes no
4th child name
Child's age
Live at home
yes no
Do you live in the city or the country?
city country
Rent or own a home
rent own
Live in
apartment
dormitory
other
If other please describe
Live with
spouse
relatives
alone
List others you live with, seperate with commas
Have you had a guide dog before?
yes no
If yes, from what school
From what agencies serving blind individuals have you received services?
Are you currently
attending college?
yes no
Are you planning to attend college in the future?
yes no
Currently employed
yes no
If yes, who is your employer?
Occupation
How is your general health?
Any other physical problems?
Medical insurance company
What type of coverage
do you have?
Insurance policy number
Name of emergency contact (relative or friend)
Relationship of emergency contact to self
Home phone of emergency contact
Work phone of emergency contact
How did you hear about Southeastern Guide Dogs, Inc.?
Which format would you prefer for future coorespondence with the school?
print
large print (20 pitch)
computer disk text files
email
cassette tapes
braille
If accepted for training with a guide dog, how much notice time do you require?
24 hours
1 week
2 week
1 month
In order to service you better with a guide dog and to assist us in understanding your needs as a future guide dog user, we request the following information. We will be contacting your references in order for us to gain a better idea of the environment in which you live and work. Please, provide the names and addresses of your references, it is most important that we have a complete mailing address including the postal zip code and apartment numbers.
Blind service or commission counselor’s name
Street address or PO box
Apartment or suite number
City
State
Zip code
Phone
Orientation and mobility instructor’s name
Street address or PO box
Apartment or suite number
City
State
Zip code
Phone
Place of employment, if employed
Street address or PO box
Apartment or suite number
City
State
Zip code
Supervisor’s name
Name of guidance counselor, if attending or planning to attend college
Name of school
Street address or PO box
Apartment or suite number
City
State
Zip code
Names and addresses and phone number of three (3) non-relative friends
Name
Street address or PO box
Apartment or suite number
City
State
Zip code
Name
Street address or PO box
Apartment or suite number
City
State
Zip code
Name
Street address or PO box
Apartment or suite number
City
State
Zip code
I understand that Southeastern Guide Dogs, Inc., will need further information and medical report before I can be accepted for training. Also, all of the information given in this application is truthful and factual.