Guide Dog Application – Freedom Guide Dogs for the Blind

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Providing Freedom and Independence to Those Who Are Blind or Visually Impaired

Guide Dog Application

Name *

First

Last *

Last

Date

Name of Spouse or Significant Other

Address

City

State State

Zip Code

County

How did you hear about Freedom Guide Dogs? How did you hear about Freedom Guide Dogs?

Date of Birth

Gender

Veteran?

Email *

Primary Phone

Mobile Phone

Previous Guide Dogs? Previous Guide Dogs?

Education- List Highest Grade Completed:

Your Profession:

Describe normal activities that would pertain to mobility with a guide dog:

If you are human, leave this field blank.

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Freedom Guide Dogs is a registered 501(c)(3). EIN:22-3136677

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