Application for a NEADS Hearing Dog

Application for a NEADS Hearing Dog

Full name:

Address:

City

State

Zip code:

Phone number:

E-mail address:

Date of birth:

Occupation:

Place of business

Days and hours employed weekly:

Work telephone:

If you volunteer, list your weekly commitment:

Have you discussed this application with your employer?

Yes No

If student, please list school name, address and current grade:

School name:

School address:

Current grade:

If student, have you discussed this application with your school's principal?

Yes No

Schooling completed:

Name of friend or relative we can call if we could not reach you:
(if applicant is minor, list parent or guardian)

Name:

Phone:

Relationship:

Brief history of your hearing loss:

Are you a veteran?

Yes No

Is your disability service related?

Yes No

Will you have further hearing loss?

Yes No

Do you use oral speech?

Yes No

Do you use sign language?

Yes No

If so please indicate what language(s)?

ADL PSE MCE

Do you need an interpreter?

Yes No

Do you lip read?

Yes No

Do you wear hearing aids?

Have you discussed this application with your doctor?

Yes No

Name of your physician:

City of physician:

State of physician:

Address of physician:

Phone of physician:

Living arrangements

Do you live in the City, Suburbs, or Rural area?

Please describe your neighborhood (busy road, neighbors close by, dogs/cats running free-examples)

How many people live with you?

Name

Relationship

age

Do you own or rent? Rent

Rent Own

If you live in an apartment ,what floor do you live on?

How many units are in your building?

If renting, have you discussed this application with your landlord?

Yes No

Do you have a fenced yard?

Yes No

Could you put up a trolley run in your yard?

Yes No

Do you have many visitors?

Yes No

What are your hobbies or interests?

Do you have any other physical limitations such as sight loss that we should consider when choosing a dog for you? (please note that hearing dogs do not perform any guiding of the blind. )

Please list your height and weight:

FT: IN: Weight:

What types of transportation do you use? (bus, car, van)

Car Bus Van Train Plane

Please list any other information that may be of help to us in selecting the proper dog for you:

Your training with the dog

I can arrange to take time off from work/school to come to the Massachusetts center to train with my dog.

Yes No

Is fatigue a factor in your daily life?

Yes No

Do you need to have rest periods during the day?

Yes No

Do you smoke?

Yes No

Are you allergic to cats?

Yes No

Dog information

A successful assistance dog applicant must be able to care for the daily need of his or her dog. Therefore we ask you to consider and answer the following: (Please indicate if you are unable to do a certain task.)

Where will you dog be taken for toilet requirements?

When do you get out of bed in the morning?

What time do you retire for the evening?

Who will help with the dog's care if you are sick or cannot get outside?

Helpers name:

Helpers phone:

Where will the dog be exercised and have playtime?

Is there a particular type/breed dog that you do not like?

Have you ever had a dog before?

Yes No

Do you or anyone in your household have a dog now?

Yes No

If so, what is the age of the dog? male/female neutered?

Age:

Sex:

Neutered:

List other pets:

Would you take your dog to work, school (if appropriate), social events?

Yes No

If not, where would the dog be?

Do you travel a lot?

Would you take the dog with you on trips?

Yes No

How many hours per day would the dog be alone?

When would you be able to start training with your hearing dog?

The size of dog I'd prefer:

The reason I want an assistance dog is:

Dog Training

All dogs are taught basic dog obedience and socialized in public situations.

To what sounds do you want your dog to alert you? (check all that apply)

Wind up alarm clock	Door knock
Electric alarm clock	Door bell
Stove timer	Door buzz
Tea Kettle	Door chime
Your name being called	Beeper
Microwave oven	Car horns (when walking)
Baby crying	Dropped car keys
Telephone	Emergency sirens when driving
Fire/smoke alarm	Dryer alarm
(If fire/smoke alarm is checked, where is the smoke alarm closest to your bedroom?

Other tasks you wish us to consider:

** Please review the information you have provided. You will not be given an opportunity to edit this information, after you click the submit button.

Thank you!