Mikey’s Kids Application – Physician or Parent

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

Applicant's Name (person making this application)*:

Applicant's Email:

Cardiac Physician's Name*:

Physician Email:

Physician Phone*:

Referring Hospital (If applicable):

Parent/Legal Guardian #1 Name*:

Parent/Legal Guardian #1 Address*:

City*:

Province*:

Postal Code*:

Parent/Legal Guardian #1 Home Phone*:

Parent/Legal Guardian #1 Cell Phone:

Parent/Legal Guardian #1 Work Phone:

Parent/Legal Guardian #1Email*:

Parent/Legal Gaurdian #2 Name:

Parent/Legal Guardian #2 Email:

Child's Name*:

Child's Date of Birth*:

Child's Diagnosis*:

Additional Information:

I authorize The Mikey Network to contact the Physician named in this application to discuss personal medical information as it relates to this application.*