The Guide Horse Foundation

Please print this document and mail to:

2729 Rocky Ford Road

Kittrell, NC 27544

The Guide Horse Foundation

Phase I Application

Part I – General Information

Full Name ((Mr. Mrs. Ms. Miss), last name, first name, middle name)

____________________________________________________________

Maiden Name or aliases (if different from above)

_____________________________________________________

Home Address:

Street________________________________________________________________

City_____________________________________ State_____________________

Zip_______________

Phone (include area code)

Home Phone_________________________________

Work Phone__________________________________

Fax ________________________________________

e-mail _______________________________________

Demographics

Date of Birth______________

Marital Status (single, married, divorced) ____________

No. of Children_____ Ages____________

Part II - Medical History

General Health (rate from 1-10) ______________

1 – Outstanding physical condition for my age

3 – Healthier that most other people my age

5 – Average health for my age

7 – Chronic physical problems

10 – Totally physically disabled

Existing Physical problems

Please list all problems for which you have visited a doctor in the past three years

_____________________________________________________________________________

Medications

Please list all prescription medications that you are currently using

_____________________________________________________________________________

Medical insurance

Company__________________________

Policy Number____________________

Medicare/Medicaid policy number _____________________________

Mental History

(Note: Answering yes to the any of these questions does not disqualify the applicant.)

Have you ever been involuntarily hospitalized for mental problems? __________

Have you ever been treated for psychiatric problems? __________

Have you ever been treated for substance abuse? __________

Visual History

Cause of Visual Loss_____________________________

Date of Onset________________________

Visual Acuity:

Right Eye____________________________

Left Eye_____________________________

Visual Field:

Right Eye_____________________________

Left Eye______________________________

Have you been trained to cane? _________________

Have you been trained use a Guide Dog? __________

If yes, please list schools, date of training, and years working with a dog:

_____________________________________________________________________________

Mobility

Please describe your typical weekly activities outside the home. Include the amount of time spent walking with a cane, and the amount of time spent per week in each activity

Outside of Home Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Time spent per week

___________________________________________________________________________

Orientation & Mobility Training History

Agency Name . . . . . . . Dates of Instruction . . . . . Instructor Name . . . . Instructor phone

___________________________________________________________________________

Rehabilitation Services History

Agency Name . . . . . . . Dates of Instruction . . . . . Instructor Name . . . . Instructor phone

___________________________________________________________________________

Part III – Personal History

Education

School .......................................Degree.................... Year

_____________________________________________________

Employment History

Employer . . . . . . . . . . . . . . Job Description . . . . . . . . . . . . . . . . . . . .Inclusive Dates

_____________________________________________________________________________

Criminal History

Please list all criminal convictions, misdemeanor or felony, the date of the offense and the outcome.

_____________________________________________________________________________

Personal References

Please list the names of three friends or acquaintances.

Name . . . . . . . . . . . . . . . . . . . Relationship to you . . . . . . . . . . . . . . . . . . .Phone number

_____________________________________________________________________________

Statement of Interest

In the space below please describe how a Guide Horse would assist you in your daily activities. Also describe why you would prefer a horse for your guide and your expectations of your Guide Horse.

___________________________________________________________________________

I understand that the Guide Horse Foundation has sole authority for accepting or rejecting all applications. I also understand that upon approval of this application, another detailed application and an on-site interview will be conducted before my acceptance for training. This application is given with the understanding that it does not obligate the Guide Horse Foundation to supply me with a Guide, and does not obligate me to accept a Guide from the Guide Horse Foundation.

Signature of Applicant__________________________________________________________________

Date_________________________________

Social Security Number___________________________

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