GDUF MEMBERSHIP APPLICATION

Date:

Applicant Name:

Birthday:

Guide's Name:

Address:

City: State: Zip Code:

Home Phone (with Area Code):

E-mail Address (if you do not have one, please leave this blank):

Please check ONE of the following:

Guide Dog: User Friend Family Supporter

Please provide us information concerning your degree of visual impairment by choosing one of the categories in the combo box below:

Degree of Visual Impairment: Select your impairment Totally Blind Partially Sighted Fully Sighted

Preference for Communications with GDUI: Select your preference Large Print Braille

If you would like to receive the quarterly issue of the magazine of Guide Dog Users, Inc, PAWTRACKS, please select one of the following formats you would prefer in the combo box below:

Format for PAWTRACKS: Select your preference I do not wish to receive it 4-track Cassette tape (for Legally-Blind Members only) Audio Compact Disc MP3 Compact Disc

Since GDUF is affiliated with the Florida Council of the Blind, we need to know if GDUF is your primary affiliate with FCB. Please choose your response in the combo box below:

Is GDUF your primary affiliate with FCB? Select your response Yes No

If GDUF is not your primary affiliate, please provide the name of your primary FCB affiliate (otherwise, please leave it blank):

Which format do you prefer for receiving The White Cane Bulletin, the FCB Newsletter, and The Braile Forum, the magazine of the American Council of the Blind? Please choose in the combo boxes below:

Format for The White Cane Bulletin: Select your preference I do not wish to receive it Large Print Braille Cassette Tape E-mail

Format for The Braille Forum: Select your preference I do not wish to receive it Large Print Braille Cassette Tape E-mail Computer CD

Thank you for your interest in Guide Dog Users of Florida. Our Annual Membership dues are $15.00. Please make your check or money order payable to Guide Dog Users of Florida, Inc.

Send your completed application to the following address:

Kathleen Trutschel
123 Palm Drive
Daytona Beach, FL 32117