Assistance dog request First name* : Last name* : If this request is for a child, names and first names of the parents* : Email* : Phone / Mobile : Your street and number* : Postal code* : City / Town* : Country* : Date of birth* : National number* : Contact person* : Phone / Mobile of contact person : AVIQ number, if you have one* : What tasks will be required of the dog?* : Are you : Student Employee Self-employed Job seeker Other You live in a : Apartment without garden Apartment with garden House without garden House with garden What are your daily and regular routines? What might your dog be exposed to?* : Do you own a vehicle? : Yes No Do you have other animals at home? : Yes No If yes, which ones? : What type of disability/illness do you have?* : If it’s not a congenital disability or illness, since when have you been in a disability situation? : You get around using : Manual wheelchair Manual wheelchair Crutches Walker If other, please specify : How does your disability affect your daily life?* : How did you hear about Os'mose?* : Are you willing to come twice a week to the Os'mose center for training? : Yes No Do you authorize Os'mose to collect your data? : Yes No Privacy policy : Yes, I agree with the privacy policy Fields marked with * are required Send my message
