Hearing Dog Guide Expression of Interest - Lions Foundation of Canada Dog Guides

Name

First

Last

Contact Email

Contact Phone

Age

Unfortunately, you do not meet the criteria for our Hearing program. For further information on what our Hearing Dogs do, please refer to our Discovery Package.

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 Hearing 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 HD-Discovery-Package.pdf

.

Do you have a medical diagnosis of moderate to severe unilateral or bilateral hearing loss, at a minimum?

Yes
No

Thank you for your interest in our Hearing 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 HD-Discovery-Package.pdf

Please list all the hearing aid devices that you currently use or have been prescribed.

Please list any other physical or medical conditions

Do you currently have a dog living in your home? As explained in the Discovery package, our Hearing Dog Guides need to be the only dog in the client’s home.

Yes
No

You MUST be willing to have a plan to rehome your current dog if you were accepted into the program. Is this an option for you?

Yes
No

Thank you for your interest in our Hearing 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 HD-Discovery-Package.pdf

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

Yes
No

Will you serve as the primary handler of the Dog Guide, taking responsibility for the dog’s training, care, task performance, behavior management, and health needs? While third-party support may be utilized during training and the dog’s working life, it should remain minimal

Yes
No

Unfortunately, you do not meet the criteria for our Hearing program. For further information on what our Hearing Dogs do, please refer to our Discovery Package.

you How Dog

Are you physically capable of working with the Dog Guide independently, including giving verbal or physical cues, offering treats (as small as an almond), and providing praise as positive reinforcement in a timely manner?

Yes
No

Thank you for your interest in our Hearing 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 HD-Discovery-Package.pdf

What assistive devices do you currently use? (e.g., wheelchair, walker, cane, etc.)?

Will the Hearing Dog Guide reside in a smoke free environment?

Yes
No

If accepted into the program, would you be available to attend in person training for up to 18 consecutive days at our facility within the next 4-18 months from the time of application?

Yes
No

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

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

Please explain