O&M Guide Dog Seminar Application

First name (required):

Last name (required):

E-mail address (required):

Address (required):
Address 1:
Address 2:

City (required):

State (required):

Zip code (required):

Phone (required):

Employer (required):

Work phone:

Work or alternate e-mail address:

Specify age group of clients you service (required):

Number of clients:

Number that currently use GPS:

Number of Guide Dog students you plan to work with per year (required):

Have you attended a professional seminar at Leader Dog before? (required)
Yes No

What type of seminar(s) did you attend?

• Guide Dog
• Trekker GPS
• Trekker Trax
• Orientation & Mobility

What date were you most recently here?

• Month: Month January February March April May June July August September October November December
• Day: Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
• Year: Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009