Contact Information:
Date of birth:    
I need a Hearing Dog to alert me to the following sounds in my home:
Fire/Smoke Alarm
Alarm Clock
Telephone (landline)
Doorbell/Door Knock
Cell Phone
My Name being called
Oven Timer
Baby Cry
I need help lifting a dog into a car
Yes   No
I can walk a dog on a leash for up to 1 mile
Yes   No
I can be steady on my feet when a small dog jumps on me, or a larger dog nudges me with his nose
Yes   No
I can maintain control of the leash of a trained dog at all times.
Yes   No
I (and anyone I live with) do not have allergies to dogs and can be around any dogs who shed.   Yes   No
I understand that Hearing Dogs can vary in size. I am physically able to be matched with:
A Small Dog   A Medium Dog   Any Size Dog (up to 80 lbs)

Pets In The Home

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

Do you live with any pets now?
Yes    No

Additional information:

Please use this space for any questions or to provide any additional information that may be helpful.

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