Before completing the application, please read the eligibility requirements. Read about the application process here.

Apply for Guiding Eyes training online by using the form below. Please note that these applications must be completed in full and submitted.  When you submit the form, a new page will appear on your screen indicating that your application has been successfully submitted and giving you further instructions.  This page will contain links to the remaining forms you will need to complete the application process.  If this page does NOT appear on your screen immediately, and you do NOT receive a call from the Admissions Department within 24 hours (including weekend if submitted on a Friday), your application did NOT submit properly.  Contact the Admissions Department by phone or email so that we may mail you the application materials, or try filling out the application and submitting it again online.  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.

Personal Information

1. Title: Select... Mr. Mrs. Ms. Miss Dr.
2. First Name (required):*
3. Middle Name:
4. Last Name (required):*
5. Suffix: Select... Jr. Sr. II III IV V
6. Email (required):*
7. Street Address 1 (required):*
8. Street Address 2:
9. City (required):*
10. State or Province (required):*
11. Zip/Postal Code (required):*
12. Country:
13. Home Phone:
14. Work Phone:
15. Cell Phone:
16. Occupation:
17. Marital Status
18. Married Single Divorced Widowed

Date of Birth

1. Month: Month... January February March April May June July August September October November December
2. 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
3. Year:

1. Cause of vision loss:
2. Date of onset
3. Distance/Central Vision Right Eye:
4. Distance/Central Vision Left Eye:
5. Peripheral/Field Vision Right Eye:
6. Peripheral/Field Vision Left Eye:
7. General Health (required): Please select a response... Poor Fair Good Excellent *
8. List physical problems, if any:
9. Medical Insurance Company (required):*
10. Medical Insurance Policy Number (required):*
11. Emergency Contact Name (required):*
12. Emergency Contact Relationship (required):*
13. Emergency Contact Home Phone (required):*
14. Emergency Contact Work Phone:
15. Who/What influenced you most in deciding to apply to Guiding Eyes for the Blind?

Correspondence Preferences

1. Correspondence Preference First Choice (required): Please select a response... Print Large Print Email Braille *
2. Correspondence Preference Second Choice: Please select a response... Print Large Print Email Braille
3. Correspondence Preference Third Choice: Please select a response... Print Large Print Email Braille

1. Professional References
   
   The Admissions Department will contact all Professional References. Please provide complete names and addresses, including zip codes.

Orientation and Mobility Training

1. If you have had Orientation and Mobility training within the past 5 years:
2. Name of Agency:
3. Agency Phone:
4. Agency Fax:
5. Agency Address:
6. Agency City:
7. Agency State or Province:
8. Agency Zip:
9. Agency Country:
10. Instructor's Name:
11. Dates of Instruction:

Rehabilitation Services

1. If you have received Rehabilitation services within the last 5 years:
2. Name of Agency:
3. Agency Phone:
4. Agency Fax:
5. Agency Address:
6. Agency City:
7. Agency State or Province:
8. Agency Zip:
9. Agency Country:
10. Counselor's Name:
11. Dates of Instruction:

1. Personal References
   
   We may contact your personal references to complete a short form about you. So please obtain their permission before listing them below. If they do not hear from Guiding Eyes, nothing is wrong.
2. List three personal references (OTHER THAN FAMILY OR PROFESSIONAL REFERENCES):

Personal Reference 1

1. Full Name (required):*
2. Street (required):*
3. City (required):*
4. State or Province (required):*
5. Zip/Postal Code (required):*
6. Email:

Personal Reference 2

1. Full Name (required):*
2. Street (required):*
3. City (required):*
4. State or Province (required):*
5. Zip/Postal Code (required):*
6. Email:

Reference 3

1. Full Name (required):*
2. Street (required):*
3. City (required):*
4. State or Province (required):*
5. Zip/Postal Code (required):*
6. Email (required):

1. Other Guide Dog Schools
   
   List any guide dog schools other than Guiding Eyes For the Blind that you have attended:

Other Guide Dog School 1

1. School Name:
2. Dates Attended:
3. Graduated?
4. Yes No

Other Guide Dog School 2

1. School Name:
2. Dates Attended:
3. Graduated?
4. Yes No

Other Guide Dog School 3

1. School Name:
2. Dates Attended:
3. Graduated?
4. Yes No

1. Your name when you attended the school(s), if different.
2. 
   By submitting this application, I understand that Guiding Eyes for the Blind, Inc. will need further information before my acceptance for training, and that completing this application places neither Guiding Eyes for the Blind nor me under any obligation.

 

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