Guide Dog Application

Applicant Details

Application Type *

Salutation *

First Name *

Surname *

Identity Type *

ID Number *

Email Address*

Mobile Number*

Occupation*

Gender *

Height *

Weight *

Marital Status *

Interest In Guide Dogs *

Employment Details

Current Employer *

What is your present occupation? *

What was your occupation before losing your sight? *

Give details,If any change of occupation is contemplated *

Have you informed your employer that you have applied for a Guide Dog? *

Will the dog be welcome at your place of work? *

Secondary Person Contact Details

First Name *

Surname *

Gender *

Phone Number *

Email Address *

Occupation *

Relation To Applicant *

Address Information

Residence *

Property *

Home Address *

Postal Address *

City *

Province *

Number of minor children *

What type of residential area do you live in? *

Are any other members of your family or household blind? *

Will a guide dog be welcome in your home?*

How many people live with you?*

Approximate size of your garden or fenced area*

Give details of any pets you currently own*

Are your dogs sterilised,Vacinated,Socialized? If not, why? *

Do you have a fully fenced garden where the dog can exercise? *

Visual Impairment & Health Details

Are you totally or partially blind?*

If partially, give degree of sight and details*

Duration of total or partial blindness*

Briefly indicate cause of blindness*

Do you have impaired hearing ?*

Please Specify *

Do you have any other disability?*

If so, please give details*

Mobility Information

Please list your current outdoor routes*

Do you use any mobility aid?*

Is it your usual habit to walk quickly or slowly?*

Do you utilize public transport – trains / taxi etc.?*

Have you attended any rehabilitation or mobility courses *

If yes , please specify*

Indicate to what extent you are able to get about unaided*

Do your usual walking routes have pavements with kerbs?*

Does your usual journeys take you through :*

Please give a brief description of what your expectations are from a guide dog*

General Information

What other clubs or Blind Welfare Societies are you a member of?*

The cost to maintain a guide dog is approximately R950.00 to R1000.00 a month. Can you afford this?*

You will be required to join pet insurance, would you be able to afford it?*

During training, the cost of the dog, accommodation and all equipment is R205.00. Is this affordable?*

Do you enjoy handling dogs?*

What prompted application/reason for application*

How did you find out about guide dog?*

Please tell us a little about yourself *

When are you available for 2-3 weeks training ?(2 weeks at out training centre and 1-2 weeks aftercare in your home environment)*

If a sudden vacant position on our Training Course occurs, will you be available at short notice?*