Personal Contact Info:

Yellow (or * )  indicates a required field

First Name *		Last Name *		Gender * M F
Birth Date *	(mm/dd/yy)
Email *		If under 18 enter parent's email
Phone 1 *	Type * Home Cell Work Parent Other
(If you are under 18 or still in High School, please list a parent as one of the phone contacts.)
Phone 2	Type Home Cell Work Parent Other
Street address *		City * State * ZIP code *

Are you intending to provide support for a specific person? If so please tell us who that is:  

---

Describe your ability to provide Guide Running

Briefly describe your background in running or track & field * (no more than two lines please)
 

What is your current average weekly training mileage?	not sure 10 or less 11 to 20 21 to 30 over 30 miles
What is the average length of a daily training run?	not sure 2 or less 2 to 4 4 to 6 over 6 miles
What is the longest training run you would be comfortable attempting?	not sure 2 or less 2 to 4 4 to 6 6 to 8 8 to 10 over 10 miles
What is your normal per mile training pace? *	not sure 7 min or less 7 to 8 8 to 9 9 to 10 10 to 11 over 11 minutes per mile

Approximate duration of time you will be available to provide guide runner support: *

3 months

6 months

1 year

Other Duration

  If 'other' please describe.

Availability schedule - please list all days of the week and times you expect to be available: *

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Morning
Afternoon
Evening

Not sure of my schedule yet

Personal statement:

What is the outcome you hope for from participation in this program? (no more than two lines please)
 

Do you have personal medical insurance? *    Yes     No

Are you willing to abide by Running Blind's Guide Runner's Conduct Pledge? *     Yes  

Add any additional comments here. (no more than six lines please)
 

Please check one to help us avoid the robo-entries.

	I am a good robot
	I am not a robot
	I am an evil robot