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 proceed with this Expression of Interest only if you are fully committed to submitting a complete application. If you are uncertain about your eligibility or have any questions regarding the qualification criteria, we encourage you to contact us at client-services@dogguides.com before continuing. Have you completed a full review of the Program Discovery Package? *YesNoThank you for your interest in our Seizure Response 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. First name *Last name *Contact email *Contact phone *Age of applicant *0Under 14 years of age1415161718192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646565+Legal guardian's nameThank you for your interest in our Seizure Response 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. A Person of Support provides emotional and physical support to you throughout your Dog Guide journey and offers an immediate, temporary home for the Dog Guide in the event of an emergency involving you. Contact Name *FirstLastContact Email *What is your preferred language? *EnglishFrenchI am bilingual in English and FrenchDo you have a medical diagnosis of intractable epilepsy (Seizures continue despite taking anti-seizure medication)? *YesNoA confirmed diagnosis of epilepsy by your family doctor is required to apply. Please note that we do not serve those with Psychogenic Non-Epileptic Seizures (PNES) or Functional Neurological Disorder (FND). Thank you for your interest in our Seizure Response 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. What year were you diagnosed with epilepsy? *Have you had seizures that involved consistent or repetitive physical movement in the past 12 months? *YesNoThank you for your interest in our Seizure Response 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. Please list any other physical or medical conditionsWill the Seizure Response Dog Guide reside in a smoke and vape-free environment? *YesNoHave 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? YesNoHow 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 EventOtherOther organization (please specify) *Other (please explain) *Submit
