BC Guide Dog Services & Alberta Guide Dog Services
 

INITIAL APPLICATION

Last Name:
First Name:
Select your title: Mr
Mrs
Ms
Date of Birth:
Street Address:
City/Town/Province:
Postal Code:
Home Phone:
Cell Phone:
Work Phone:
Email Address:
How long have you resided at your current address?
Are you contemplating a move in the near future? Yes
No
If yes, when?
What year did you become visually impaired?
What is the cause of your visual impairment?
Have you had Have you had Orientation & Mobility Training? Yes
No
Are you using a long cane for independent mobility? Yes
No
How often do you leave your home independently? - for example to visit friends, run errands
Have you previously had a guide dog? Yes
No
If yes, from which Organization(s)?
If yes, how many guide dogs have you worked?
Are you currently working a guide dog? Yes
No
If yes, from which Organization?
When did you retire your last guide dog?
Do you have any limitations that affect your mobility (such as other disabilities)?
Is this your first application to BC & Alberta Guide Dog Services? Yes
No
Have you applied to any other guide dog schools? Yes
No
If yes, when did you apply?
I understand that completing this form places neither me nor BC Guide Dog Services under any obligation, but assists BC Guide Dog Services in determining my eligibility for training. Yes, I agree with the Privacy Policy

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