KSDS Guide Dog Application Request
Average wait: 4 1/2 - 5 years from date of application acceptance
KSDS Assistance Dogs, Inc.
120 W 7th St.
Washington, KS 66968
785-325-2256
Fax: 785-325-2258
snutsch@ksds.org
Applicant Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Work Phone
Mobile Phone
E-mail
*
Applicant Age
*
Must be 14 years or older
Parent Name (if applicant is a minor)
Has the applicant been legally declared blind by an Ophthalmologist?
*
Yes
No
Degree of Blindness
*
Cause of Blindnesss
*
Duration of Blindness
*
Has the applicant had orientation and mobility training?
*
Yes
No
If yes, when and where was the training?
If the applicant has hearing loss, describe it.
Additional Information
Submit
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