HEARING DOG APPLICATION. Dear Applicant: In order to expedite the application-process; please ensure that you enclose the following:

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1 HEARING DOG APPLICATION Dear Applicant: In order to expedite the application-process; please ensure that you enclose the following: q Complete Application Form q Medical History Form q Hearing Dog Applicant Language Self-Evaluation Form q Autobiography q Personal Reference Letter q Audiology Report (Hearing Dog Applicants Only) q Recent Photo q Map and directions to your home q $ Application Fee It is your responsibility as an applicant to ensure that the Pacific Assistance Dogs Society receives all of these documents. Please do not assume that your Doctor or Personal Reference has sent these forms. Your application will not be processed until all the above items are completed and returned to our office. After you complete the application and it is received, you will be contacted to set up an interview appointment. Attached Photo Here ************************************************************************************ IMPORTANT NOTE: All information submitted to the Pacific Assistance Dogs Society within this application package will be handled with the strictest confidence and will only be available for viewing by authorized PADS employees. All personal information will be stored in a secure location and will not be released without first obtaining permission from the applicant. Applicants will be considered for a PADS assistance dog regardless of race, gender, religion or creed and will be treated with respect and dignity. ************************************************************************************ PADS Hearing Dog Application 1

2 APPLICANT NAME PHONE: Home Work Cell ADDRESS CITY POSTAL CODE DATE OF BIRTH AGE HEIGHT WEIGHT WORK ADDRESS NAME OF NEAREST RELATIVE RELATIONSHIP ADDRESS OF RELATIVE PHONE : Home Work CURRENT LIVING ARRANGEMENTS: ( ) Live Independently ( ) Live with Parents ( ) Group Housing ( ) Other (please explain) Are you able to travel to the PADS facility for your personal interview? ( ) Yes ( ) No, why? ************************************************************************************ Using an Assistance Dog can be a tremendous asset to a person's life and quest for independence. However, it is also a serious and long-term commitment and responsibility for the life and well-being of another living creature. We hope that you will reflect carefully upon your answers to the following questions and respond openly and honestly. There are no right or wrong answers to these questions, so please don't feel as if this is a test which you could pass or fail. The questions have been designed to give us a better understanding of who you are as a person, so that we might better match you with the right Assistance Dog. We will discuss these areas further during your interview. *********************************************************************************** History Percentage of hearing loss: Mild Moderate Severe Profound Do you wear a hearing aid? ( ) Yes ( ) No How well do you hear with it? 2

3 Can you understand telephone callers? Do you read lips? Use sign language? Can you speak? Date of Deafness Cause General Health (if you have other disabilities, please specify) Education Name of High School School for the Deaf College Special Training Residence Who else lives in your home? (List each person below and indicate if they are deaf or hearing): Name Age Relationship Deaf/Hearing Does anyone living in your home have handicaps or special needs? Dwelling type: House Townhouse Apartment Rural Other Please draw a diagram of the layout of your home, including the location of doors, telephones, smoke alarms, alarm clocks, timers, etc. 3

4 Do you have a dog now? ( ) Yes ( ) No 4

5 Any other pets? Will you be willing to give up your present dog? ( ) Yes ( ) No If you have a dog now, do you wish to be put on a waiting list? ( ) Yes ( ) No What size of hearing dog would you prefer? Small Medium What sounds do you need to be alerted to? List in priority order. How many times does someone come to your door per day? Per Week? How many phone calls do you get per day? Per Week? Would you take your dog to: Work? ( ) Yes ( ) No School? ( ) Yes ( ) No Please describe your lifestyle and activities Are you able to afford the cost of feeding and veterinary care of your own Hearing Dog? ( ) Yes ( ) No If Yes, how will you meet this commitment? Have you made your key care professionals aware of your application for a Hearing Dog? e.g. teacher at school, physical therapist, occupational therapist, etc. ( ) Yes ( ) No PLEASE READ CAREFULLY The placement process requires one week; 3 days at the PADS Training Center and 2 days at your home. During this time, please be prepared to spend MOST of your time with the dog and our instructor. Waiting lists, your location and availability of dogs will determine when your Hearing Dog will be placed with you. If your application is approved, your name will be placed on our waiting list for a Hearing Dog. When a dog becomes available, a placement date will be scheduled. 5

6 A several month adjustment period must be expected before you and your new Hearing Dog are working together as a team. Obedience training must be maintained throughout the dog's working career. A Hearing Dog is a "working" dog, not a "pet". Children or other people must not be allowed to interfere with the dog while he is working in the home because this could distract him from alerting you to an important sound. I have read and understand the above statements. SIGNATURE DATE 6