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Guie EoUsers of Canada

By Louis Gonzales,2014-03-20 14:29
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Guie EoUsers of Canada

     Guide Dog Users of Canada

    Utilisateurs de chiens-guides du Canada

    PO Box 66582 ; 685 McCowan Road ; Scarborough ON M1J 3N8

    http://www.gduc.ca ; 1 (877) 285-9805

    Registered Charity #869175190RR0001

    Wellness Fund Application

    April 2009

    The Guide Dog Users of Canada Wellness out, if accompanied by an itemized invoice Fund was established to provide assistance or receipt detailing the costs involved. to Canadian guide dog handlers who face

    necessary, extraordinary veterinary costs to If funding is approved before a treatment ensure that their guide dog can continue has been undertaken, that approval is valid working. Costs related to a retired guide for a maximum of six (6) months. dog who is still living with his or her handler

    may also be considered at the discretion of What information is needed? the Committee. Applicants must provide a completed

    application form, a completed veterinary Who may apply? report from their treating veterinarian, and Any person who would normally be receipts, estimates, or invoices in support of considered to be eligible for Active the amount requested. Among other things, membership status in Guide Dog Users of this information will include the handler’s Canada is eligible to apply to the Wellness name and contact information, the dog’s Fund for assistance with these costs. In particulars, the diagnosis and proposed essence, this means that the individual treatment(s), the dog’s prognosis, and what must be blind or partially sighted, and that other sources of funding the handler has their dog must have been trained at a considered or attempt to secure. recognized guide dog training facility.

     If funding is approved, we will require

    original receipts in support of the The applicant may apply to Guide Dog

    Users of Canada, or their veterinarian may application. If the applicant requires those submit an application on their behalf if the receipts for their own records (e.g. income veterinarian is to be paid directly. tax) or for other funding applications, we will

    return them after the request has been

    processed. When do I have to apply?

    Applications must be received by Guide

    Other Funding Sources Dog Users of Canada no more than six

    months after the related treatment or event As a first step, applicants are advised to occurred. speak with their guide dog’s training school

     to inquire about the availability of funding to Applications may be submitted prior to assist with veterinary costs. If a school has carrying out or approving a procedure, if declined to assist with an extraordinary accompanied by an itemized estimate of veterinary expense, please indicate why on the costs involved. Alternatively, your application form.

    applications may be submitted after the

    treatment or procedure has been carried

    below and mailing or faxing them, with Eligible Expenses

    supporting documentation, to Guide Dog Only non-routine, extraordinary, and Users of Canada. Alternatively, the emergency veterinary expenses will be applicant and/or their veterinarian may considered for reimbursement from the complete the online applications forms Wellness Fund. Everyday costs of owning available at a guide dog are not generally eligible for http://www.gduc.ca/applyforwellness. reimbursement including, but not limited to, costs relating to: Supporting documentation: Applicants must provide an itemized estimate, invoice, ; Annual checkups and vaccinations; or receipt from their veterinarian in support ; Municipal licensing fees; of their application. This documentation ; Food; may be attached to an online application, or ; Grooming and boarding; faxed or mailed to GDUC, as applicable. ; Non-essential or cosmetic veterinary or dental work; or Please

    ; Transportation charges relating to PRINT CLEARLY AND LEGIBLY ordinary veterinary appointments (in capital letters) on application forms! (emergency travel or travel to specialists to be considered on a Applications and supporting materials may case by case basis). be sent to: In most instances, the Wellness Fund will GDUC Wellness Fund not provide ongoing funding for the PO Box 66582 treatment of a chronic, recurring or long-685 McCowan Road term condition (such as the need for Scarborough ON M1J 3N8 specialized food).

    Via email: guidedogs@gduc.ca Maximum Funding Limits Via fax: 1-877-285-9805 (please call Each application is considered on its own this number by voice first, merits, but as a guideline, minor procedures as it is used for both fax and (with a cost under $100) will likely be voicemail)

    covered in their entirety. Unless special

    circumstances exist, the maximum amount You may also apply online, by visiting that will be awarded from the Wellness http://www.gduc.ca/applyforwellness.

    Fund is typically 50% of the overall cost of

    the procedure to a maximum of $500.00. Applications will be acknowledged upon

     receipt, and a funding decision will No single applicant may receive more than generally be rendered within 2 weeks of $500.00 in funding from the Wellness Fund receipt.

    in a 12 month period without approval from

    Guide Dog Users of Canada’s board of

    directors. Questions?

    If you have any questions about the How do I apply? Wellness Fund or the application process, Applicants, or their veterinarians, may apply please e-mail us at guidedogs@gduc.ca or

    by completing the paper application forms call 1-877-285-9805 for assistance.

    Guide Dog Users of Canada

    Wellness Fund Application

    Applicant Form

    PLEASE PRINT IF COMPLETING THIS FORM BY HAND

    (If you are completing this form electronically, place

    your answer to each question after the caret: ^) A. Information about you (the handler)

Name (first and last): ^

Mailing address (include street, city, province, and postal code): ^

Telephone (home): ^

Telephone (alternate): ^

E-mail address: ^

    Preferred method of contact (mail, phone, e-mail): ^

    B. Information about your dog

Name: ^

Breed: ^

Gender (male, female): ^

Date of birth (or age): ^

Dog status (retired, working): ^

C. Information about your guide dog school

School name: ^

School location: ^

School telephone number: ^

    Has your guide dog school been advised of the need for this treatment? (Yes or no): ^

If not, why not? ^

D. Information about funding sources

    Have you approached your guide dog school about their possibly funding, or assisting with funding, this procedure? (Yes or no): ^

If not, why not? If your request was denied, why was it denied (if you

    know)? ^

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

    E. Information about your treating veterinarian

Vet’s name (first and last): ^

Vet’s business name (if any): ^

Vet’s phone number: ^

Vet’s e-mail address: ^

If the veterinarian report is not included with your application, how is it

    being sent to GDUC? (online, mail, fax, email?) ^

F. Your funding request

Total expenses relating to this incident: ^ $

Have these expenses already been incurred? (yes or no) ^

Amount requested from the Wellness Fund: ^ $

If approved, who should be paid? (handler, vet, other) ^

    Is there any other information or are there other circumstances that you believe to be relevant to your application? (Attach additional sheets as

    required if completing this form by hand) ^

G. Declarations

    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 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.

    ___ 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 will seek a second opinion on my dog’s health situation if the Wellness

    Fund Committee requests this of me.

     ____________________________________ __________________

    Signed: (Guide dog handler) (Date)

    Guide Dog Users of Canada

    Wellness Fund Application

    Veterinary Report Form

    PLEASE PRINT IF COMPLETING THIS FORM BY HAND

    (If you are completing this form electronically, place

    your answer to each question after the caret: ^)

A. Applicant Information

Name of handler (first and last): ^

Name of dog: ^

B. Information about you (the treating veterinarian)

Name (first and last): ^

Business Name (if any): ^

Mailing address (include street, city, province, and postal code): ^

Telephone: ^

Fax: ^

E-mail address: ^

    Preferred method of contact (mail, phone, fax, e-mail): ^

For how long have you treated this dog (in years)? ^

C. Information about the dog

Date of initial diagnosis (yy/mm/dd): ^

Diagnosis: ^

Recommended Treatment: ^

Prognosis: ^

Following treatment, will this dog be returning to work? ^

Will more than one treatment be required? Explain: ^

What is the expectation for remission and type of follow-up treatments,

    if any? ^

    What is the estimated or actual cost of treatment? (Include an itemized invoice or estimate.) ^

Is there any other information or are there other circumstances that you

    believe to be relevant to this application? (Attach additional sheets as required if completing this form by hand) ^

     ____________________________________ __________________ Signed: (Treating Veterinarian) (Date)

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