Hypoglycemia Alert Dog Application Contact Information Applicant Name Birth Date, Age Facilitator Name Relationship to applicant Birth Date (applicant under 18) Street Address City ST ZIP Code Home Phone # Cell Phone # Work Phone # E-Mail Address Facilitator Email (if different from above) Diabetes Type Please check the most appropriate description of your Diabetes Type 1 (Childhood) Type 1 (Adult onset) Pump? Type 2, Non- Insulin Dependent Type 2, Insulin Dependent Monitoring method
Hypoglycemia Events How often do you experience Hypoglycemia in a week? How often are you unaware of your Hypoglycemia? How often do you need medical attention because of Hypoglycemia? What is a typical low blood sugar level for you? What is the lowest blood sugar level you ve gotten to? Please describe a typical Hypoglycemia event. Please include any physical, emotional and mental symptoms that you experience. Please include as many details as possible. Feel free to use additional pages. Other Physical Conditions What other physical challenges do you have? Please describe any reduced strength, range of motion or sensitivity of any limb, neuropathy, difficulty with wound healing or other conditions that would need to be considered when matching you with a dog. Daily Activities Please describe your typical activity level. Include school or work, hobbies, therapies, regular MD appointments etc. How do you get around? (drive yourself, get rides, public transportation).
Other Activities Please describe any other activities that you participate in (travel, family visits, concerts, etc.) where you would take your dog. General Information How many pets do you currently have? (please give their type, breed and age)
Do your pets live inside or outside? Have you had dogs before? (If yes, please give their breed, when you had them and where they are now) Who lives with you, or comes to your house regularly? Is anyone allergic to dogs? (Please give their names, ages and relationship to you) Please describe your housing and your neighborhood. Will your dog have access to a fenced exercise area? If not, how will your dog get exercise? Do you plan to move in the next year? Have you or anyone who lives with you ever been convicted of a felony? Have you or anyone who lives with you ever been investigated for animal cruelty or neglect by law enforcement or a humane organization? Caring for a Service Dog typically costs about $1000 each year. The dog s partner is responsible for, among other things: Veterinary care Recommended food Daily and Weekly grooming Heartworm Medicine Flea Control Emergency care It will be very important that you treat your Service Dog as a working dog, not a pet. This means not allowing strangers to pet or feed your dog without your permission, making sure that your dog behaves well in public, and being responsible for your dog s care and well being. Does anyone in your household have any concerns about having a Service Dog in your home? (If yes, please explain)
Alternate contact Please give us the name of someone that we can contact if we can t reach you, or if we need to contact someone for you in case of an emergency. Name Street Address City ST ZIP Code Home Phone Work Phone E-Mail Address Personal References Please provide the name, address, phone number and email of 3 people who are not related to you but know you fairly well. Please have at least one of these people complete the Personal Reference Form in this packet. 1. 2. 3. Medical References Please provide the name, address, phone number and email of at least one medical professional who knows you and your medical history well. Please remember to have one of them fill out the Medical Reference Form in this packet. 1. 2. Fundraising Contacts The cost to ICAN of raising and training one Service Dog is between $17,000 and $20,000. We are committed to passing on only $1300 of that cost to you. Please list the names and contact information for individuals, companies and foundations that you can contact to help offset the additional costs for your dog. 1. 2. 3.
Agreement and Signature I attest that the information I have provided in this application is accurate, truthful and up-to-date to the best of my knowledge. Enclosed is my $40 non-refundable/ tax deductable application fee to Indiana Canine Assistant Network (ICAN). I hereby give permission to ICAN to use my name, city and photographic image in its printed brochures, newsletters, videotapes, press releases and fund raising efforts. This permission continues until such time as I give ICAN written notice rescinding said permission. Name (printed) Signature (parent or guardian if applicant is a minor) Date