Apply for a MIRA Guide Dog

Please Read - MIRA USA accepts applications beginning with a child's 9th birthday. We begin the process of pairing children with guide dogs at the age of 11 and serve children up through the age of 16. 

 

Both the parent and applicant must be a citizen of the United States.

Contact Information

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Email*
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Phone*

Applicant Information

 

Please feel free to elaborate on any answers.

For Visual ImpairmentWe are looking for:

Visual Acuity (a number such as 20/400, or Light Perception Only, or No Light Perception NLP, etc.)

Degree of Field of View - If candidate has a limited field of view please describe. (such as less than 10 degrees, unimpaired or normal.)

 

 

Candidate's First & Last Name
Candidate's Date of Birth
Visual Impairment ---- Left Eye Visual Acuity / Field of View
Visual Impairment --- Right Eye Visual Acuity / Field of View
How long has the candidate been blind?
Cause of Blindness?
Use a white cane? Around community, school, or both?
Regularly work with an Orientation & Mobility instructor? How often? For how many years?
How are the candidate's skills at street crossings? Please elaborate.
Does the candidate have additional complications other than blindness?
Additional Comments

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