Hearing Dog Program Application Step 1 of 9 11% CONTACT INFORMATIONName(Required) AgeAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact NumbersHomeWorkCell Text Video Relay TTY Email How do you prefer to be contacted? Mail Phone Email Text Have you ever had a Hearing Dog before? Yes No If yes, who trained the dog for you?When did you get her/him?Do you still have your Hearing Dog? Yes No If yes, how old is s/he?:If no, where is s/he now? HEARING LOSS OVERVIEWDo you consider yourself deaf or hard of hearing? Deaf HOH If deaf, when? Since birth or as an adult? If HOH, when did your hearing loss begin? What is your current hearing loss level? profound severe moderate mild left ear only right ear only both ears What degree in each ear? Can you hear on the phone? Yes No How well?Can you read lips? Yes No Do you sign ASL? Yes No Assisted Listening Device? Yes No Closed Captioning? Yes No When you have a conversation, one-on-one, how do you prefer to communicate?Attach an audiogram or similar test from your audiologist or doctor.Max. file size: 512 MB.When you’re in a classroom or group setting, how do you prefer to communicate?How would you feel most comfortable communicating to your Hearing Dog? Voice Sign Both Which sounds are most important for your Hearing Dog to alert you to? ?(Please circle all that apply) Door Bell Door Knock Name Being Called Kitchen/Oven Timer Phone Call Alarm Clock Other If Other, please specify HEALTH OVERVIEWTo accommodate any physical or emotional issues you may have, please answer these questions honestly and as complete as possible. This information is kept confidential and is only used to help match the right dog with you, based on your specific needs. Do you use a? Cane Walker Wheelchair mobility device motorized chair Other?Do you have any of the following? Visual impairment Impaired Dexterity (hands) Depression High Blood Pressure Asthma Heart Condition Back Pain Fibromyalgia Limited Mobility (legs) Balance issues Anxiety Diabetes Restless Leg Syndrome Tinnitus Chronic Pain Vertigo Limited range of motion(arms) Allergies (other than food) Stress Carpel Tunnel Gout Neuropathy Arthritis Other Please circle all that applyOther Additional InformationIn general, would you describe your health as good, fair, poor? Good Fair Poor In general, how active are you? Very active Moderately active Not very active Are you on any medications? Yes No If Yes, please list. HOUSEHOLD/LIVING SITUATIONWhat type of housing? House Condo Duplex Mobile Home Boarding House Apartment Flat Townhouse Share a room? Other please circle all that apply and describe house structureOther? Attach pictures of your home (front, back and side yards) and interior living areas.Max. file size: 512 MB.Is this a single or multiple unit dwelling? Single Multiple Unit Does it have an elevator? Yes No Does it have stairs? Yes No If Yes, how many flights? Do you own or rent? Own Rent If rent, who is the landlord?List all members of your household (living with you): Name Age Relationship To You Deaf/Hoh/Hearing Name Age Relationship To You Deaf/Hoh/Hearing Name Age Relationship To You Deaf/Hoh/Hearing Are there any service animals in your household? Yes No If Yes, describe animalsDo you have an enclosed, fenced, private yard? Yes No If yes, describe the fence (material and height) and provide dimensions of yard:Attach pictures of your yard, including fenceline.Max. file size: 512 MB.If no, please describe where you will let your dog out to potty and for exercise?How far is it? How many other dogs use it? Are there any pets in your house? Yes No If yes, number of dogs? Number of cats? Other? Do you intend to move within the next 12 months? Yes No If yes, where and when? LIFESTYLEIn order to get to know you better and to select a Hearing Dog that best matches your lifestyle, please answer this section with as much detail as you want. You may attach a separate page if you like.What are your hobbies?What are your interests?What physical activities do you do?What activities do you plan to do with your Hearing Dog?Describe your own personality and character:What do you do on a daily basis/often? DOG HISTORYHave you ever had a dog? Yes No If yes, what type, sex, age? When? Where is s/he now?Have you ever trained a dog? Yes No If yes, what type of training did you do, with whom and where?How would you describe your dog handling skills? Excellent Good Average Not very good Briefly describe your experience with dogs:Are you able to bathe, groom and care for your Hearing Dog on your own? Yes No If no, who is able to help you? DOG NEEDSIn order to match the right dog with you, let us know what you prefer in a Hearing Dog. However, the more flexible you are, the sooner you may get a dog, because most of our dogs come from shelters. We don’t select dogs by breed or color, rather, all of our dogs are selected based on good behavior, personality and their ability to be trained as hearing dogs.What type of dog do you like? What type do you NOT like? What characteristics do you like?What do you NOT like?What size dog do you prefer? Small (under 20lbs) Medium (20-39lbs) Large (over 40lbs) Do you prefer: male female no preference (all dogs are spayed or neutered)Do you prefer: short medium long haired dog no preference Do you have any other preferences? TRAVEL/COMMUTEWhich of the following pertain to you? Drive your own car Have someone else drive you Use paratransit or taxi Bicycle Travel by airplane (domestic or international) Walk, jog Ride public transportation (bus, subway, rail, streetcar, ferry…) (Circle all that apply and how often per week for each.)EDUCATIONAL BACKGROUNDAre you currently in school, college, vocational rehabilitation, training or other institution? Yes No If yes, where? Please attach current class schedule (days of week and time of day)Max. file size: 512 MB.Would your Hearing Dog go to school with you? Yes No What is your highest level of education? High School Some College Special training AA BA MBA Vocational Rehabilitation Other If Other Do you plan to return to school or training? Yes No If yes, where and when?Would your Hearing Dog go to school with you? Yes No EMPLOYMENT HISTORYAre you currently working? Yes No If yes, where? (company) Supervisor’s name? Phone number? How long have you worked there? What type of work do you do (include title)? How many hours a week do you work/what days? Do you have? a private office cubicle shared office space no office classroom other If Other How many people are in your office? Would your Hearing Dog go to work with you? Yes No If Yes, where would s/he stay/rest? If No, where would s/he stay? If not currently working, where did you last work? What type of work ? How long there?Are you retired? Yes No If yes, when? What type of work did you do? When did you retire?What type of work do you normally do (if different from last job)?Do you plan on returning to work or changing careers? Yes No If yes, when, where and what hours? Type of work?INCOMEBecause taking care of an animal can be costly (food, treats, veterinary bills, grooming, emergencies, boarding, supplies, on-going training…), we need to assess your income. This information is kept confidential and is only used to help match you with the right Hearing Dog (size, breed). Also, if on certain Federal and State programs, you may qualify for some benefits.What is your total monthly income (include all sources)? $ per monthAre you on disability? Yes No If yes, what type? How long?Do you have income other than your current job? Yes No If yes, what type? How much do you plan to have available for your Hearing Dog? $ per monthREFERENCESPersonal reference: (someone who knows you and can speak to your dog care ability)Name Address City State Zip PhoneEmail Attach a letter addressing your experience with dog training, handling and care.Max. file size: 512 MB.Professional reference: (someone who can speak to your hearing loss needs and abilities)Name Address City State Zip PhoneEmail Attach a letter addressing your need to have a Hearing Dog and how it would benefit you.Max. file size: 512 MB.Is there anything else we should know about you?***If there are any changes to the information on this form, you must update your file immediately or you may lose your place on the applicant list.***Signature Printed Name Date MM slash DD slash YYYY If someone else completed this form for you, who did?Signature Printed Name Date MM slash DD slash YYYY If you are submitting this form online, please print this page, sign it and mail it to the Hearing Dog Program, 2912 Diamond St, Suite 221, San Francisco, CA 94131-3208. 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