Guide Dogs of Hawaii Registration Form Survey

1.This form filled out by: (staff initials)

CLIENT CONTACT INFORMATION

2.Full name:(Required.)

3.Residential address:

4.Mailing address:(Required.)

5.Best phone number we can reach you at:

6.Email address:

7.Date of Birth:(Required.)

8.Gender (For statistical purposes only):(Required.)

Female

Male

Prefer to self-describe

9.Ethnicity (For statistical purposes only):

10.Annual Income (For statistical purposes only):

11.Language Spoken:

12.Do you need a language interpreter:

Yes

13.Are you a Veteran:

Yes

14.Are you currently receiving Services from any agency such as Ho’opono DVR, ATRC, Abilities Unlimited, Helen Keller Foundation, etc.? If Yes, please specify:

15.What service animal or guide dog, if any, do you use?

16.How did you hear about GDH?

A client

Website

Referred by

17.Please specify your preferred method of communication:

Phone

Other (please specify)

SECTION 2: ELIGIBILITY

18.Cause of legal blindness:

19.When were you determined legally blind?

20.Proof of Legal Blindness (form N-172, certification from MD, DVR, VA, COMI):(Required.)

21.Proof of Residency (utility bill, State ID, Handi-Van Pass, etc.)(Required.)

22.Emergency Contact (must be 18 or older)(Required.)

23.Full Name(Required.)

24.Phone(Required.)

25.Relationship(Required.)

CONSENT STATEMENTS

26.I understand that by registering I am a client entitled to request for available services and enroll in periodic projects that I may be eligible for and that I may be required to provide additional information that will help to determine my eligibility for requested services or periodic project enrollment.(Required.)

I authorize the release of any and all information about me to personnel, associates and authorized agents that will determine my eligibility for services.

I authorize the use of my name, likeness and testimonies to be used to educate and/or promote GDH services.

I agree to volunteer at least 10 hours a year to educate, promote and fundraise for Guide Dogs of Hawaii,

I understand that it is my responsibility to keep GDH Informed of any and all changes to my contact information and action plans.

27.Signature(Required.)