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

Please note that the Guide Horse Foundation is new, and we consider our program to be experimental.

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___________________________

Guides Training Press Photos News Apply FAQ Wishes Contact Home

Helping Hooves
Training Miniature Horses as Guide Animals for the Blind

Janet Burleson

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The Guide Horse Foundation has the utmost respect for The Seeing Eye® and their seventy-two years of outstanding work with assistance animals for the blind. Even though the press often calls our horses "seeing eye horses", please note that The Guide Horse Foundation is not affiliated with or sanctioned by the Seeing-Eye® or any of the Guide Dog training organizations. Seeing-Eye® is a registered trademark of the Seeing-Eye, Inc.

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