Seizure Response Dog Guide Expression of Interest Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.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. Do you have a medical diagnosis of intractable epilepsy (not able to be controlled by medication)? *YesNoThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. Age of applicant *0Under 16 years of age161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646565+Thank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. Legal guardian's nameThinking about the last 4 weeks, how many seizures have you experienced? More than 2Less than 22Thank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. When you experience a seizure, do you exhibit consistent physical movement? YesNoUnsureThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. Province or territory of residence *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonWhat is your preferred language? *EnglishFrenchI am bilingual in English and FrenchContact email *Contact phone *Please list any other physical or medical conditions: *If accepted into the program, would you be available to attend in person training for up to 21 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 our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. Do you currently have a dog living in your home? As explained in the Discovery package, our Seizure Response Dog Guides need to be the only dog in the client’s home. *YesNo, I do not have a dog living in the homeWould you be able to rehome the dog if you were accepted into the program? *YesNoThank you for your interest in our program Unfortunately, you do not meet the criteria for our program. For further information on what our Seizure Response Dogs do, please refer to our Discovery Package. Will the Seizure Response 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 Seizure Response Dogs do, please refer to our Discovery Package. Submit