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.

Is this application being filled out by the child’s doctor or a family member?*:–Select One–DoctorFamily Member

Physician’s Name* 
Physician’s Phone* 
Referring 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 

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.*