Wellness Fund Application - Applicant/Handler

Please complete the below form to submit an application for funding to the Wellness Fund. Supporting documentation should be mailed or otherwise sent separately.

Handler Information

Handler Name (first and last):: *

Address (Line 1): *

Street address (e.g. 141 South Beach Road)

Address (Line 2):

Apartment number, etc. (e.g. Suite 1414)

City: *

Province: *

Postal Code: *

Telephone (Home/Primary): *

Telephone (Alternate):

E-mail Address:

Preferred method of contact: *

About the Guide Dog

Dog's Name: *

Breed: *

Gender: *

Dog's Date of Birth (or age): *

Dog's Status: *

Guide Dog School

School Name: *

School Location: *

City and Province/State

School Phone:

Has the guide dog school been notified of the need for this treatment?: *

If the school has not been notified, explain why:

Funding Sources

Have you approached your guide dog school for funding assistance with respect to this incident?: *

If you have not approached your school, why not? If you have, what was the outcome of that discussion?:

Including yourself, please identify any other sources (and amounts) of funding that are available to help cover these expenses:

Treating Veterinarian

Vet's Name: *

Vet's Business Name (if any):

e.g. Centrepoint Veterinary Hospital

Vet's Telephone Number: *

Vet's Email (if any):

Funding Request

Total expenses relating to this incident: *

Have these expenses already been incurred/paid?: *

Amount requested from the Wellness Fund: *

If your application is approved, who should be paid?: *

Supporting Documentation

How will you be submitting your supporting documentation (receipts, bills, etc.): *

How will your vet be submitting his/her veterinarian report form?: *

Additional information or comments that you believe may be helpful:

Declarations

Please read and agree to the following conditions prior to submitting your application to the Wellness Fund.

Guide Dog Users of Canada/Utilisateurs de chiens-guides du Canada (GDUC/UCGC) is committed to protecting your privacy and maintaining the confidentiality of the Personal Information that is collected through this application, the veterinary report, and supporting documentation. GDUC/OCGC will not share your Personal Information with third parties except as authorized by you below, or as required by law. Please see http://www.gduc.ca/en/about/privacy (new window) or call us at 1-877-285-9805 to receive a copy of our complete privacy policy.

By submitting this application, veterinary report and supporting documentation, I agree (by marking each item below) that:

I warrant that I am a Canadian citizen who is a blind or partially sighted handler of a guide dog trained by a recognized training facility and that all information provided herein is complete, accurate, and truthful to the best of my knowledge.

I meet the eligibility criteria outlined above: *

I agree that Guide Dog Users of Canada, its directors and representatives may communicate with my veterinarian and/or guide dog school with respect to this application, if deemed necessary in the assessment of the application.

I agree that GDUC may contact my veterinarian and/or guide dog school as required: *

I will seek a second opinion on my dog’s health situation if the Wellness Fund Committee requests this of me.: *

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Wellness Fund

Wellness Fund Application - Applicant/Handler