Hearing Dog Application

Welcome and thank you for choosing to apply for a Hearing Dog!

Our application process involves several guided steps which helps us determine if we are the right program for you. If approved to our waitlist, wait times can vary before being matched with a dog, but are generally up to 1 year. For dogs considered “hypoallergenic” or non-shedding of any size, there may be a considerably longer wait time due to availability constraints.

Qualification for a Hearing Dog is determined through several steps in our application process. For a Hearing Dog to be helpful, your hearing loss must meet a minimum severe loss in both ears or experience difficulty hearing common household sounds more than 50% of the time day or night. We will ask you to upload an audiogram at the end of this form.

The Sam Simon Foundation does not require an application fee to be considered for a Hearing Dog. Once we have had an opportunity to evaluate your application, we will notify you by mail or email with next steps.

If you have any questions or run into any problems completing our fillable online application, please notify us by email or phone.

info@samsimonfoundation.org

310-457-5898 (ext: 2)

We look forward to working together and appreciate your trust in us to help you navigate this process.

To save your in-progress application and continue at a later date, please scroll to the end of the application and click “Save & Continue Later”.

Hearing Dog Application

"*" indicates required fields

Before filling out my application, I certify that I have read and understand the Hearing Dog Readiness Checklist.*

Review the The Hearing Dog Readiness Checklist

Yes, I understand

Contact Information

Name*

First Last

Street address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing address

If different from the street address above.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Who is completing this application?*

The client (recipient of services)

Not the client

Preferred method of communication.*

Phone

Relay

How do you communicate on the phone?*

Check all that apply.

TDD

Hear on the phone

Use VCO

Use VRS

How do you communicate in person?*

Check all that apply.

Read lip

Read lip, some/a little

Sign language

Sign language, some/a little

Voice

Voice, some/a little

Emergency Contact

Name*

of emergency contact

First Last

Relationship*

to emergency contact

Phone*

of emergency contact

Applicant Background

I live in a*

House

Apartment/Condo

Duplex

Retirement Facility

Mobile Home

Rent a room

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

Do you rent or own your home?*

Rent

Own

If you rent, please provide the name of your complex.

If you rent, please provide your landlord's name, phone number, and address.

Describe the home environment and where the dog would live.*

E.g.: size, number of rooms, upstairs, downstairs, noisy, cluttered, etc.

Do you have a yard?*

Yes

Is your yard fenced?*

If you have a yard that is not fenced, but can be fenced, we may ask that you to do this as a condition of acceptance.

Yes

If your yard is fenced, what are the dimensions?*

Could a cat escape through or under your fence?*

Yes

Please describe the type of fencing.*

E.g.: chain link, wood, cement, and the size of all gaps.

Sound Awareness

Hearing Dogs are trained to alert you to sounds in your home and in some workplaces. They can also be trained to specific sounds such as the door knock or alarm clock in hotels. They do not provide this same awareness out in public situations such as the mall or grocery store. In these situations, a Hearing Dog is naturally attentive to environmental sounds and it becomes the responsibility of the deaf or hard of hearing partner to watch where their dog’s attention goes to be aware of those sounds.

I need a Hearing Dog to alert me to the following sounds in my home:*

Fire/smoke alarm

Telephone (landline)

Cellphone

Oven timer

Alarm clock

Doorbell/door knock

My name being called

Baby’s cry

What other sounds not listed above, if any, do you want to know if a dog can be trained to work for you?

Do you wear hearing aids?*

Yes

If you wear hearing aids, when do you take them out?

Do you have a cochlear implant?*

Yes

If you have a cochlear implant, when do you take the unit off?

If you do not currently have a cochlear implant, do you plan to have one and if so, when?

Please describe your hearing loss.*

What sounds you can hear in your home? What sounds do you most often miss both in and out of your home?

Please check that you have read and understand that a Hearing Dog is not trained to:*

Select all to show you understand.

Be a guard dog.

Alert to sounds in public spaces.

Pull me out of the way of on-coming traffic.

I understand it is my responsibility to pay attention to my dog’s reaction to sounds while in public to make me more aware of my surroundings.*

Yes, I understand.

Lifestyle

Date of birth*

Age*

Height*

Weight*

Marital status*

Single

Married

Separated

Widowed

Do you have children?*

Yes

Someday

If you have children, how many and what ages?

If you have children, how comfortable are they around dogs?

Work/School

Do you work outside the home?*

Yes

If you work outside the home, do you plan to take your dog with you?*

Yes

If yes, please describe the environment at work and where your dog will be while you are working:

What does your supervisor say about you bringing your Hearing Dog to work? Are they supportive?

If you attend school, will you be taking your Hearing Dog to class with you?*

Yes

If yes, what is your field of study and what is your class schedule?

If you do not plan to take your dog to work or school with you, where will your dog be while you are gone?

Dog Experience

Have you ever had dogs before?*

Yes

If yes, what kind(s) and when did you last own a dog(s)?*

How long did you have each dog?*

Describe some regular activities that you did with your previous dog(s).*

What is your idea of a good exercise routine for a dog? How many minutes each day can/will you spend helping your dog exercise?*

Do you have any other pets?*

Yes

If yes, what kind and how many, and are they used to being around dogs?*

I ____ to play with dogs*

do not like

I ____ when dogs lick me.*

mind

do not mind

I ____ to take dogs for a walk.*

do not like

I ____ a dog following me around the house all day.*

mind

do not mind

I ____ my dog to have access to my entire house.*

want

do not want

I ____ a dog on the furniture.*

mind

do not mind

Comments for any of the above:

Size of Dog

Is there any size or breed of dog you do NOT want?*

I understand that I need to be able to…*

Select all to show you understand.

Lift my dog into a car.

Walk my dog on a leash.

Have a dog jump or ‘paw’ me.

Keep control of my dog at all times.

I understand most Hearing Dogs are between 12lbs–50lbs. I have enough strength to handle a dog that weighs:*

Under 12lbs

Up to 25 lbs

Up to 35 lbs

More than 35 lbs

Other Dogs in the Home

The Sam Simon Foundation Assistance Dogs Program does not place Hearing Dog in homes with other dogs. The distraction has proven to be too difficult for the Hearing Dog. Other pets such as cats and birds are acceptable, if the other pets are not aggressive towards dogs.

Do you live with other dog(s) now?*

Yes

If yes, please provide the following information for each dog: Breed, Age, Primary Owner, Indoor/Outdoor.*

Applicant Health and Fitness

Check all medical conditions that apply to you:*

List all allergies

List any medical conditions not included above.

I get out of bed daily.*

Mobility

Yes

I can get up and down from a chair.*

Mobility

Yes

Comments on mobility.

I have a problem with my balance.*

Balance

Yes

I am able to handle a large dog jumping on me.*

Balance

Yes

I am able to handle a large dog pulling on its leash.*

Balance

Yes

Comments on balance.

I have restricted use of my arms or hands*

Yes

Comments on use of arms or hands.

I use a wheelchair.*

Yes

Comments on wheelchair use.

I use other mobility aids.*

Yes

If you use mobility aids, please list all and provide any additional comments.

I require the assistance of an aide or family member for daily living skills.*

Yes

List all medical doctors/health care providers, and their specialities, that currently treat you.

Family Assistance

For a Hearing Dog to be successfully placed with you, everyone living in your home must like dogs and be happy living with a dog. They must be willing and able to support you having a dog and assist with the care of your dog when you are unable to do so.

I have talked with everyone I live with about getting a Hearing Dog. They support my decision to apply for a Hearing Dog.*

Yes

If no, comments:

I have talked with everyone I live with about their willingness to support a dog working for me. Everyone I live with (including caregivers) agrees they will assist me with the care of my dog when I am unable to do so.*

Yes

If no, comments:

People living in my home like dogs.*

Yes

If no, comments:

People living in my home are afraid of dogs.*

Yes

If yes, comments:

Who will take care of your dog if you are temporarily unable to do so?*

List all other people living in your home.*

Please include: 1. Name 2. Age 3. Relationship to you 4. Any physical/emotional challenges 5. Work/school schedule

List all other people who visit your home frequently.*

Please include: 1. Name 2. Age 3. Relationship to you 4. Any physical/emotional challenges 5. How often they visit

Certified Hearing Dog in Public

Please select the answer that most accurately reflects your expectations for a Hearing Dog.*

I plan to take my dog into public places at least 3 times a week.

I do NOT plan to take my dog into public places at least 3 times a week.

I work (or attend school) in an environment that is safe and comfortable for a dog and I will be taking my dog with me and will need my dog to alert me to sounds there.

I work (or attend school) but I do NOT want to take a dog with me.

If you do not plan to take your dog with you to work or school how will your dog be cared for while you are there?*

If you need to leave your Hearing Dog home alone on occasion, who will be available to care for your dog (take out to relieve himself and for exercise?)*

Needs and Expectations

Describe a typical day for you.*

Include both weekdays and weekends.

What are your concerns regarding adopting a Hearing Dog?*

Please check that you understand the following:*

Please check all to show you understand.

I understand that Hearing Dogs are chosen for their people-friendly manners and that they are not trained to be guard dogs.

I understand that a Hearing Dog is certified to accompany me in public places such as restaurants, doctor’s offices, and stores.

I understand that a Hearing Dog cannot be helpful for me unless he/she is with me most of the time.

Please share any comments or concerns on the above.*

Financial

Our trained Hearing Dogs are provided to you free of charge, but you are solely responsible for all costs of keeping your dog fed, healthy and working for you. Normal, on-going costs for a Hearing Dog include, but are not limited to: dog food, toys and treats for training rewards, regular vet check-ups, and sometimes emergency vet treatments, and grooming. We estimate the yearly cost of having a dog to be approximately $1,000 annually. We do not recommend you apply for a Hearing Dog if it will be a financial hardship.

Please check that you understand the following:*

Check all to show you understand.

I understand that I am fully responsible for the cost of care of the dog after it comes to live with me.

I expect to, and am able to, pay for all veterinary expenses.

I understand that to keep a Hearing Dog working, I will need to buy pet supplies such as toys and treats on an on-going basis.

I understand that I need to feed my Hearing Dog a high quality dog food.

How will you pay for the needs of a Hearing Dog?*

Chose one and fill in the blank at the next question.

I can afford to pay whatever it costs to keep my dog healthy and working for me.

I can afford to pay up to $______________. If this is not enough, I have a family member willing to provide financial support. Name of family member: ______________________.

I can only afford to pay up to $_____________. I do not have a family member able to provide financial support.

Fill in dollar amount and name of family member willing to provide financial support.*

Fill in dollar amount.*

In the event of an extreme veterinary emergency expense:*

Choose the option that best fits.

I will take care of the bill myself.

I will be able to get financial assistance from friends/family.

I will need special financial assistance.

My source(s) of income is:*

About Yourself

What is the best experience you can remember having with a dog?*

What is the worst experience you can remember having with a dog?*

How do you expect a Hearing Dog to help you?*

List 5 words that you would use to describe yourself.*

Additional Information

Have you ever applied for a Hearing Dog before?*

Yes

If yes, from whom and what was the decision?

Have you ever received a Hearing Dog from another organization before?*

Yes

If yes, when and from whom?

If you have had a Hearing Dog from another organization before, why are you applying for one from The Sam Simon Foundation?

How did you hear about the Assistance Dogs Program at The Sam Simon Foundation?*

Have you, or anyone living in your home, ever been convicted of a felony?*

Yes

If yes, who, when, and what was the felony?

Release of Liability & Statement of Client Rights

To be considered for a SSF Dogs Hearing Dog, please review our Release of Liability and Agreement to Indemnify and Statement of Client Rights and enter your name below as an electronic signature to certify your understanding.

I have read and understand the Release of Liability and Agreement to Indemnify.*

Signature

I have read and understand the Statement of Client Rights.*

Signature

Applicant Audiogram

To be considered for a SSF Dogs Hearing Dog, you will need to supply an audiogram (hearing test).

Please upload a signed and completed audiogram release and questionnaire.

Max. file size: 50 MB.

Signatures

By typing your name where indicated below, you certify that you understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

I hereby declare all information in this application to be truthful.*

Signature

Date of signature*

If applicant is under 18 years of age, legal guardian's signature:

Signature

If a Conservator or Guardian has been assigned, please sign here:

Signature

Comments

This field is for validation purposes and should be left unchanged.