Chien-guide d’alerte au diabète Manifestation d’intérêt Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.Please only proceed with this Expression of Interest if you are fully committed to applying. If you are unsure whether you meet the qualification criteria or have questions, please email client-services@dogguides.com First name *Last name *Have you reviewed the program discovery package in full? *YesNoI'm not sureThank you for your interest in our program Before continuing, please review our Discovery Package with all you need to know about the program. Click here for further details. How did you hear about Lions Foundation of Canada Dog Guides (LFCDG)?LFCDG Facebook/ InstagramLFCDG eventsMedia Release (news)Referral from family member or friendReferral from LFCDG client or volunteerReferral from Lions ClubGoogle searchSocial MediaHealthcare ProviderOther organizationCommunity EventOtherWhich organization? *Which Community event? *Please explain *Do you have a medical diagnosis of Type 1 (Insulin Dependent) Diabetes with hypoglycemic unawareness? *YesNoThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Diabetes Alert Dogs do, please refer to our Discovery Package. When were you diagnosed with diabetes? *Under 1 year ago1-5 years ago6+ years agoThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Diabetes Alert Dogs do, please refer to our Discovery Package. Age of applicant *Under 16 years of age161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646565+Thank you for your interest in the Diabetes Alert program Unfortunately, you do not meet the age criteria for our program. However, if you or someone you know is between 5-16 years old with Type 1 diabetes and lives within 2 hours of Oakville, please reach out to our client services department at client-services@dogguides.com for more information on eligibility for a new pilot program. Legal guardian's name Province or territory of residence *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonContact email *Contact phone *What is your preferred language? *EnglishFrenchI am bilingual in English and FrenchHow many lows (below 4.5 mmol/L) per week do you consistently experience? *An average of 23More than 3Please list any other physical or medical conditions: *If accepted into the program, would you be available to attend in person training for up to 15 consecutive days at our facility within the next 4-18 months from the time of application? *YesNoHave you applied for a Dog Guide from our organization previously? *YesNoDoes anyone in your home have allergies to dogs? *YesNoThank you for your interest in the Diabetes Alert program Unfortunately, we are not currently taking applications for those who require a hypoallergenic dog. Please check back the next time we reopen to new applicants. Do you currently have a dog living in your home? As explained in the Discovery package, our Diabetes Alert Dog Guides need to be the only dog in the client’s home. YesNoWould you be willing to rehome the dog if you were accepted into the program? *YesNoWe do not permit other dogs to reside in the same household as a Diabetes Alert Dog, as these specialized dogs must maintain a high level of independence and focus to effectively carry out their critical tasks. Having other dogs in the environment could interfere with their ability to perform their duties reliably. Will the Diabetes Alert Dog Guide reside in a smoke free environment? *YesNoThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Diabetes Alert Dogs do, please refer to our Discovery Package. Submit
