Date____________
NAME:__________________________________
STREET ADDRESS:____________________________________
CITY, STATE, ZIP _____________________________________
PHONE:_______________________
EMAIL:
Which of the following best describes your condition:
Sighted___ Partially sighted____ Blind___
Do you use a guide dog? ____ Dog's name (optional) __________
What school is your dog from? (optional) ____________________
As a member of Guide Dog Users of Arizona, you are also a member of the American Council of the Blind and entitled to receive the "Braille forum."
Please choose your preferred medium (below):
Braille _____ Audio Tape____ Large Print_____ Email____
What is your preferred medium for receiving printed mailing from Guide Dog Users, Inc.?
Email____ Braille____ Large Print____
What is your preferred format for "Paw Tracks"
(quarterly newsletter from GDUI)
4-track tape______
Audio CD _____
Please send your completed registration form, along with a check or money order for $10 made payable to "Guide Dog Users of Arizona" (or "GDUA") to the address below:
Jacque Olsen - Treasurer
423 E. Fairmont Drive
Tempe, AZ 85282-3720
Any questions please call or Email Jacque at:
Phone: telephone: 480-894-0712
e-mail: websterolsen@cox.net
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