MIRA FOUNDATION INC.

APPLICATION FORM

SERVICE DOG

Name: ______Surname: ______

Address: ______City: ______

Province: ______Postal code: ______

Home phone number: ______Work place phone number: ______

Fax number: ______Email: ______

Date of birth: ______Civil status: ______Sex: ______

Occupation: ______Weight: ______Height: ______

If the above person is a child, write below the name and contact information of the person responsible for that child.

Name: ______

Kinship: ______

Address: ______

HEALTH AND DISABILITY ISSUES

Describe the diagnosis you have received in general and medical terms:

When have you been diagnosed? ______
Is your condition stable or evolutionary? ______

Do you have associated impairments? (Diabetes, high blood pressure, etc)?

______

Do you suffer from other health problems? If yes, please indicate their nature.

Do you suffer from allergies? If yes, please indicate their nature.

Do the relatives who will also live with the dog suffer from allergies? If yes, please indicate their nature.

*Do not forget to attach to your application a copy of your medical certificate filled by your doctor.

.

Do you receive rehabilitation services (physiotherapy, occupational therapy, neuropsychology, etc.)? Please write the name and contact information of the persons that assist you.

Ø 
Ø 
Ø 

*Please attach a report from each professional if available.

Check the answers that best describe your capabilities in certain situations.

I CAN: / YES
Easily / YES
With some difficulty / NO, I CAN NOT
Explain why
Pick-up an object off the floor / With a clamp
Other: / :
Press elevator buttons / With a stick
Other: / :
Open doors / Yes, only lever door handles
Yes, unless the door is heavy
Yes, except in confined areas
Other: / :
Undress myself (jacket, coat, socks, shoes) / Painfully
Other: / :
Transfer myself from my chair to my bed / With a patient lift
With a board
Other: / :
I CAN: / YES
Easily / YES
With some difficulty / NO, I CAN NOT
Explain why
Pick myself up
off the floor / With my wheelchair
Supported by a furniture item
Supported by a walking auxiliary
Other: / :
Propel my wheelchair / Indoors or on level ground only
Anywhere, but over short distances only
I can propel my wheelchair, but it causes me pain
Other: / :
Walk / Indoors or on level ground only
Anywhere, but over short distances only
Other: / :
Use the stairs / A few stairs only
With a handrail only
Other: / :

PLACE OF RESIDENCE

Residential neighbourhood Urban area Rural area

House Apartment Other: ______

Do you own your home? YES NO

Is your home space adapted to your needs? YES NO

What are your indoor and outdoor accommodations?

Access ramp / Elevator / Lifting platform / Automatic door / Adapted bathroom
Lowered countertop workspaces / Support bars, floor to ceiling poles / Environmental control system / Track lift / Other:

FAMILY Environment

You live: / Alone / With a spouse / With one or more roommates / With your family

Please list the persons living in your home. Please include their name, age and relationship to you.

Do all the people living with you agree with your approach? YES NO

If some of them do not encourage you, please describe their worries:

Do you have other pets at home? Please include their age, breed and if they have been sterilized or not. Please include all pets and not only dogs.

Have you ever owned a dog? YES NO

If yes, what breed? ______

LIFESTYLE: Most of the time, I stay home

I am active and very often go out in my community

SOCIAL SITUATION

Ø  EMPLOYEMENT

I am retired I work as a volunteer

I work part-time full time

Did you discuss the possibility of bringing a service dog to work with your employer?

YES NO

Ø  STUDIES You study/attend:

Via a correspondence course Elementary school High school CÉGEP University

Did you discuss the possibility of bringing a service dog to your school with the director of the establishment? YES NO

TECHNICAL ASSISTANCE Please check the ones you use and where.

Mobility aid / Indoor use / Outdoor use
Cane
Crutches
Walker
Rollator
Manual wheelchair
Motorized wheelchair
Four-wheeled scooter

EXPECTATIONS

Do you think that a mobility dog could help you increase your autonomy in your daily activities? If yes, in which domains?

support assistance transfer assistance help pick myself off the floor
walking assistance contribute to wheelchair traction help me undress
help pick-up objects off the floor door opening assistance help press door and elevator buttons
Other activities that could be offset by the mobility dog:

Do you wish to be evaluated in order to benefit from the Programme de remboursement de frais relatifs à l’utilisation d’un chien d’assistance à la motricité in the eventuality of a dog acquisition?

YES NO

CONSENT

I authorize the training school to ask and communicate information deemed necessary for the evaluation and processing of the application for a mobility dog to the concerned and competent organizations in the field, notably the professionals working with the Reimbursement program and health care workers. This authorization is valid for the whole period covering my application addressed to the training school as from the date of signature of the consent and can be revoked at any time.

Applicant signature: ______Date: ______

If you have been unable to write to fill this form yourself, who filled it for you?

Name: ______Relationship to you: ______

Date: ______

We thank you for your confidence.

/ MIRA FOUNDATION, INC.
1820 rang Nord-Ouest
Sainte-Madeleine (Québec) J0H 1S0
Phone: 450-795-3725│ 1-800-734-6472
Fax: 450-795-3789
│ www.mira.ca / APPENDIX 1
FORM
MEDICAL REPORT
Your patient has presented a request for a guide dog with the Mira Foundation. Our three-week training is rigorous and will not depend on weather conditions. For us to provide your patient with the proper training for his/her physical condition, we ask that you kindly fill out this form.
LAST NAME: / FIRST NAME:
DATE OF BIRTH:
Your patient suffers, or has suffered, from the following diseases:
q  Hearing loss
q  Convulsive seizure, loss of consciousness, dizziness
q  Orthopedic disorder
q  Nervous system disorders
q  Paralysis
q  Equilibrium
q  Epilepsy
q  Coordination
q  Emotional maladjustment
q  Digestive disorder (if yes, please see attached sheet)
q  Nervous impairment
q  Allergies / q  Rheumatism or arthritis
q  Asthma
q  Cancer
q  Hernia
q  Tuberculosis
q  Serious injuries
q  Impaired circulation
q  Other physical disorders
q  Renal or urinary problems
q  Hepatitis
q  HIV
Please explain any positive response in the above list:
Please describe any pulmonary disorder history:
Please describe any cardiac, hypertension and stroke history:
Please describe any specific diet and indicate medications and daily dosage:
ATTENDING PHYSICIAN SIGNATURE / DATE
/ MIRA FOUNDATION, INC.
1820 rang Nord-Ouest
Sainte-Madeleine (Québec) J0H 1S0
Phone: 450-795-3725│ 1-800-734-6472
Fax: 450-795-3789
│ www.mira.ca / APPENDIX 2
FORM
DIABETES REPORT
DIET: / CALORIES PER DAY:
ORAL MEDICATION: / DAILY DOSAGE:
INSULIN
Dosage (morning): / INSULIN
Dosage (morning):
Does your patient perform his/her own injection? yes no
Does your patient perform his/her own insulin test? yes no
Does your patient adjust his/her own insulin dose? yes no
Does your patient perform his/her own blood sugar test? yes no
Blood sugar test method used:
Date and result of latest blood sugar test:
Date and incidence of latest coma or insulin shock:
Please describe any specific diet and indicate medications and daily dosage:
Please note any secondary complications (neuropathy, nephropathy, etc.) and special instructions and/or suggestions:
EXAMINATION DATE FROM WHICH THIS REPORT IS BASED:
ATTENDING PHYSICIAN SIGNATURE / DATE

Service dog application form Page 1 of 1