Diabetes Alert 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 *Contact email *Contact phone *Have you reviewed the program discovery package in full? *YesNoAge of applicant *0Under 14 years of age1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646565+Legal guardian's name Province or territory of residence *AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonWhat is your preferred language? *EnglishFrenchI am bilingual in English and FrenchThank you for your interest in our Diabetes Aler Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources please refer to the Discovery Package. Do you have a medical diagnosis of Type 1 (Insulin Dependent) Diabetes? *YesNoThank you for your interest in our Diabetes Aler Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources please refer to the Discovery Package. When were you diagnosed with diabetes? *Under 1 year ago1-5 years ago6+ years agoThank you for your interest in our Diabetes Aler Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources please refer to the Discovery Package. Thank you for your interest in our Diabetes Alert Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources, please refer to the DAD-Discovery-Package.pdf How 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 Diabetes Aler Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources please refer to the Discovery Package. Have you or any member of your household been, or are you subject to, a court order banning you from the ownership of any animal(s)? *YesNoHave you ever been convicted of a criminal offense? *YesNoThank you for your interest in our Diabetes Aler Dog Guide Program. After reviewing your information, we regret to inform you that you do not meet the eligibility criteria for the program at this time. For more information about the program, including eligibility requirements and resources please refer to the Discovery Package. How did you hear about Lions Foundation of Canada Dog Guides (LFCDG)? *Social MediaLFCDG eventsMedia Release (news)Referral from family member or friendReferral from LFCDG client or volunteerReferral from Lions ClubGoogle searchHealthcare ProviderOther organizationCommunity EventOtherWhich organization? *Please explain *Which Community event? *Submit
