Canine Vision Dog Guide Expression of Interest - Lions Foundation of Canada Dog Guides

Name

First

Last

Contact Email

Contact Phone

Age

Thank you for your interest in our Canine Vision 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 CVC-Discovery-Package.pdf

Legal Guardian’s Name (if applicable)

City

Province or Territory of residence

What is your preferred language?

Have you completed a full review of the Program Discovery Package?

Yes
No

Thank you for your interest in our Canine Vision 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 CVC-Discovery-Package.pdf

.

Have you been medically diagnosed as legally blind (defined as visual acuity of 20/200 or worse in the better eye with corrective lenses, or a visual field of 20 degrees or less in the better eye)

Yes
No

Thank you for your interest in our Canine Vision 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 CVC-Discovery-Package.pdf

Have you had prior orientation and mobility training?

Yes
No
Self-taught

Are you able to independently navigate in your community safely and effectively?

Yes
No

How often do you walk independently within your community in a week?

Please list any other physical or medical conditions

What assistive devices do you use?

Do you or anyone in your home have allergies to dogs?

Yes
No

We are not currently taking applications for those who require a hypoallergenic dog. Please check back the next time we reopen new applications.

Will the Canine Vision Dog Guide reside in a smoke and vape free environment?

Yes
No

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?

Yes
No

the training you

Have you applied for a Dog Guide from our organization previously?

Yes
No

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)?

Yes
No

Have you ever been convicted of a criminal offense?

Yes
No

Thank you for your interest in our Canine Vision 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 CVC-Discovery-Package.pdf

How did you hear about Lions Foundation of Canada Dog Guides (LFCDG)?

Please explain