Physicians or parents of a child in need of a MIKEY, can apply using the form below. If you are an organization looking to place a MIKEY at your location, please use the application here. The Mikey Network is a registered Canadian charity, governed by rules and regulations set forth by the Canada Revenue Agency. Our charter limits us to only consider requests for a MIKEY defibrillator from residents of Canada. Fields with (*) are required. Cardiologist’s Name* Cardiologist’s Phone* Affiliated Hospital* Parent/Legal Guardian Information: Parent/Legal Guardian #1 First Name* Parent/Legal Guardian #1 Last Name* Parent/Legal Guardian #1 Phone* Parent/Legal Guardian #1 mobile Parent/Legal Guardian #1 Email* Parent/Legal Guardian #1 Address Street* City* Province* Postal Code * Parent/Legal Guardian #2 (optional) Parent/Legal Guardian #2 Name Parent/Legal Guardian #2 Last Name Parent/Legal Guardian #2 Email Child’s Name* Child’s Date of Birth* (Please use this format: MM/DD/YYYY): Child’s Diagnosis* Additional Information Is this application being filled out by the child’s doctor or a family member?*:–Select One–DoctorFamily Member By checking this box and submitting this form, you agree to the following: I authorize The Mikey Network to contact the Physician named in this application to discuss personal medical information as it relates to this application.*