GDUF MEMBERSHIP APPLICATION

Please complete then print out this application.

Date:

Last Name:

First Name:

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 Family Supporter Friend

Please provide us with your level of visual impairment by choosing one of the categories in the combo box below:

Level of Visual Impairment: Select your impairment Totally Blind Legally Blind Sighted

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

Guide Dog Users, Inc. publishes a quarterly magazine called "PAWTRACKS." If you would like to receive this publication, please select your requested format below. PLEASE NOTE that the audio cassette format is available to VISUALLY IMPAIRED persons ONLY.

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

Since GDUF is affiliated with the Florida Council of the Blind, we need to know if GDUF is your primary affiliate. 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 in the edit box below (otherwise, please leave it blank):

Which format do you prefer for receiving the following publications? Please choose in the combo boxes below:

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

Format for The Braille Forum (American Council of the Blind Magazine): Select your preference I do not wish to receive it Large Print Braille Audio Cassette E-mail

Guide Dog Users of Florida is proud to have a listserv in which to share information. Often, Members like to offer birthday wishes to one another and/or their Guide Dogs. If you would like to be placed on our listserv, please indicate in the combo box below:

Would you like to join the GDUF Listserv? Select your response Yes No

If you would like to receive birthday wishes for you and/or your Guide Dog, please provide us with your birthdays below:

Birthday (month and day, in numbers only):

Guide Dog Birthday (month and day, in numbers only):

Membership for Guide Dog Users of Florida is $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:

Roger Graham
759 Licaria Dr.
Ocoee,, FL  34761-3949

Please contact Roger with any further questions regarding this application. Call him at (407) 654-6782 or E-mail sixsides@aol.com.

Thank you for your interest in Guide Dog Users of Florida. We look forward to your participation. Together, we can make a difference.

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