Guide Dog Personal Reference Form

Applicant Information

Applicant's First Name

Applicant's Last Name

Reference Information

Reference's First Name

Reference's Last Name

Address Line 1

Address Line 2

City

State

Province

ZIP Code

Country

Personal

How long have you known the applicant?

What is the nature of your relationship (i.e. friend, neighbor)?

In what ways have you seen the applicant adjust to living with vision loss?

How does the applicant handle stressful or challenging situations?

Can you share an example of how the applicant makes decisions or shows good judgment?

How does the applicant typically participate in social settings or gatherings?

How would you describe the applicant’s style of communication with others?

What have you noticed about how the applicant maintains their home environment?

In what ways does the applicant spend time outside the home on a regular basis?

Does the applicant have sufficient income to care for a guide dog (approx. $120/month)?

YesNo

Does the applicant have pets currently or in the past?

YesNo

Does the applicant have a guide dog currently or in the past?

YesNo

Does the applicant care for pets or a guide dog appropriately?

YesNo

Travel

Does the applicant use a white cane when walking?

YesNo

What type of destinations does the applicant independently travel to in their home area? (E.g. stores, park, etc.)

Type of transit used? (E.g. car, bus, shuttle, train, etc.)

Does the applicant cross major lighted intersections independently?

YesNo

Is there anything else you’ve noticed about the applicant’s travel skills or habits?

YesNo

Health & Independence

Is the applicant able to manage medical conditions and medications independently?

YesNo

How would you describe the applicant's stamina for walking or other activities?

Does the applicant have a history of alcohol or substance abuse?

YesNo

If so, please explain:

In your opinion, how might a guide dog be helpful to the applicant?

Is there anything else you'd like to add about the applicant's home life, health, or independence?