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Apply for a hearing dog

Who can apply?

If you:

are severely hard of hearing or profoundly deaf
need assistance to be made aware of sounds like the alarm clock, doorbell, telephone, smoke alarm etc.
want to feel independent from your family or colleagues, or if you spend a lot of time alone
can provide a dog with proper exercise, grooming, food and medical care (help may be given if this is difficult for you)
would enjoy the close company of a dog, and want to build a working partnership with one
don't have other dogs at home (except perhaps for an elderly pet dog)
are over 18 years of age

How to apply

You can contact us by phone, letter, fax or email to ask us to send you an application form.

Alternatively, you can complete the application form online.

Your application form will help us to assess whether a hearing dog could help you, and will secure your place on the provisional waiting list. The next step will be for someone from Hearing Dogs for Deaf People to visit you at home to explain the benefits and responsibilities of having a hearing dog.

Application form

This application form is for residents of England, Scotland, Wales and Northern Ireland only.

For overseas enquiries please contact Assistance Dogs International via the link found in the links section.

Please complete all sections of this form.

Once we have received your form we will arrange to visit you to discuss your application further.

Your details

Items marked with a * are required

Date of application:

* Full Name:

* Address:

* Postcode:

* Date of birth:

dd-mm-yyyy

Home telephone number:

Do you have a minicom?

Yes No

What type:

Fax number:

* E-mail address:

Mobile telephone number:

Preferred mobile phone method:

Voice Text

Do you have a hearing friend, relative or neighbour we can call if we need to contact you?

Name:

Relationship:

Telephone number:

History

Date of Deafness:

dd-mm-yyyy

Cause:

* Degree of Deafness:

Mild Moderate Severe Profound

General health at present:

Do you have any other disabilities?

Do you use sign language?

Do you have oral speech?

When did you last have a hearing test?

Have you seen a Hearing Therapist?

Name and address of your hospital / audiology clinic:

Name and address of doctor:

Occupation

Occupation:

Present employer:

Work address:

Work telephone:

Hours of work:

No contact with your employer will be made without your permission.

Residence

Do you live in a:

House Flat Bungalow Mobile home

If you live in a flat which floor?:

Do you intend to move house in the next 6 months?

Yes No

If Yes give approximate dates:

If you do not own your home, are you allowed to keep a dog?

Yes No

Landlord's name:

Landlord's address:

Do you have a garden?

Yes No

Is it fenced?

Yes No

Do you live alone?

Yes No

Give the name, age and relationship of each person in your home:

Name

Age

Relationship

Deaf / Hearing

Does any member of your family suffer from any severe allergy, including an allergic reaction to dog hair?

Yes No

Details of allergy:

Please list any pets in your home at present, including dogs (please give age and breed of dog)

Have you ever had a dog before?

Yes No

What type?

Would you take your dog to work / college?

Yes No

How many hours would you be away from the dog, at:

Weekends:

hours

Weekdays:

hours

Are you financially able to provide for the dog's food and medical care?

Sounds

If your application is accepted, which sounds would you like your dog to be trained for?

Baby alarm

Baby's age:

Alarm clock

Telephone

Door knock

Bell Buzzer

Cooker timer

Burglar alarm

Security buzzer

Other sounds (please explain)

What size dog would you prefer:

Please give reasons why you feel a hearing dog would be helpful to you.