Completing your application for a ADMP Hearing Dog:

  1. Fill out the form on this page and send to THSD by pressing the Submit button at the end of the form page.
  2. The Counselor Form and Medical Background Form must be printed from your browser and given to appropriate persons to fill out.
  3. If you would like to have forms mailed to you, please call (877) TEX-DOGS (839-3647) or e-mail Shane at Debbie@servicedogs.org.
  4. Proof of injury during deployment is required. Please mail a Copy of your Deployment or your DD214
  5. There is a $25 application fee.
  6. Please mail both the appliation fee and a Copy of your Deployment to ADMP c/o THSD, 4803 Rutherglen, Austin, TX 78749.

      7. Application Form
      Section I: Background
      Name:
      Address:
      City: Zip:  
      E-Mail Address:
      Home phone:     Work phone:    
      Your age:       Spouse's Age: 
      Employer:
      Spouse's Employer:

      Work Days and Hours:
          Sunday From     to  
          Monday From     to  
          Tuesday From     to  
          Wednesday From     to  
          Thursday From     to  
          Friday From     to  
          Saturday From     to  
       


      Please give the name of a friend or relative we can call if we can't reach you:
       
      Name:      Relationship:

      Phone:      Work phone:

      Are you or anyone living with you allergic to dogs?    Yes    No
      If yes, who is allergic and to what extent?  
      Describe your hearing loss:  
      Number of years with hearing loss:       Cause of hearing loss:  

      Section II: Home
      Marital status:  Single   Married   Divorced   Separated   Widowed 

      How many people live with you?     Please list the people who live with you:
      Name Age    Relationship:
        
        
        
        
        
        

      Current living arrangement (check all that apply):
      Live independently
      Live with parents
      Live with attendant
      Others       		In a house
      In an apartment
      In trailer home
      In group housing

      Are you currently receiving government benefits? Yes    No

      Do you use a wheelchair? Yes, manual    Yes, power    No

      Please describe other specialized equipment you use (mouthstick, van lift, special car keys, etc.):  

      Section III: Lifestyle
       
      Height:   ft.   in. Weight:   lbs.

      Physical challenges:
      Mobility
      Endurance
      Heat sensitivity
      Pain sensitivity       		Physical strength
      Reaction speed
      Speech difficulty
      Other:  

      Activity level:    Low    Moderate    High

      Please list any additional health problems (e.g. diabetes, epilepsy, cerebral palsy, etc.):

      Describe your leisure activities (TV, visit friends, team sports, shop, travel, computers, eat out, etc.):
      If you are a student, where do you attend school?   

      Section IV: Pet History
       
      Have you ever had a dog?    Yes    No
      Do you have a dog now?    Yes    No
      If yes, what kind?    How old is the dog?
      Please list any other pets you have now:  

      Section V: Living with a Hearing Dog
       
      A Hearing Dog needs daily training, attention, love and care. Do you commit to provide the following:
      Veterinary care? Yes    No Recommended food? Yes    No
      Heartworm medicine? Yes    No Flea control? Yes    No
      Weekly grooming? Yes    No Emergency care? Yes    No

      Do you also commit to the following:
      Yes    No Prepare for and participate in a one hour training session in your home with the trainer, two times each week.
      Yes    No Follow the trainer's instructions on feeding, housebreaking, and bathing.
      Yes    No Practice training with the dog ("homework") 15 minutes each day.
      Yes    No Treat the dog as a working dog, not just a pet. That means not allowing strangers to pet the dog in public without your permision, making the dog behave in public, and being the only person in your family responsible for the dog's care.
      Yes    No Keep the dog in good health. That means taking it to the veterinarian when necessary, giving the dog heartworm preventative (chewable tablet-monthly kind or daily kind), treating the dog, your home and yard for fleas in flea season, anything else necessary for the good health of the dog.
      Yes    No Telling the trainer if you or the dog are having any problems with training, obedience or any other questions.

      Will the dog travel with you?    All the time    Sometimes    Never
      Do you plan to take the dog to your workplace?    Yes    No
      Do you consider yourself knowledgeable about dogs?    Yes    No
      Do you have strong feeling about what traits you like and dislike in dogs?    Yes    No
      If so, what are they?
      Are you willing to adapt your lifestyle and/or attitudes to meet your dog's ongoing physical and psychological needs (e.g. a Service Dog lives indoors full-time)?    Yes    No
      Are you prepared for the responsibility of adopting another member into your family for the next 7 to 10 years?    Yes    No
      Are the individuals with whom you live willing and prepared to allow you full charge of the Service Dog?    Yes    No

      Section VI: You and Your Environment

      How do you deal with your anger toward personal friends?

       
      Towards authority figures?

       
      Towards animals?

       
      How do you respond to frustration towards people?

       
      Do you consider yourself self-motivated or do you rely more on encouragement and emotional support of others? Please explain:

       
      Do you plan to take the Service Dog to work, shopping malls, grocery stores, and other places, after you complete training? Please explain:

      Section VII: Medications
       
      Please list all medications you are currently taking, the dosage (e.g. 25 mg. 2 times per day), and their purpose. This MUST be a complete list. If you need more room, please use additional paper or e-mail a complete list.
       
      Name Dosage Purpose:






      Section VIII: Description of Request
      Please explain why you would like to have a Hearing Dog:
      Hit the Submit button to email this form, or print and mail this form, as well as the Counselor Form and Medical Background Form to:
      Texas Hearing & Service Dogs, 4803 Rutherglen, Austin, Texas 78749.
      Please also mail the $25 application fee.