Application

NEADS Hearing Dog

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  = Required Information

Personal Information

First Name
Last name
Street Address
City
State
Postal Code
Phone Number
Email
Date of Birth
Month
Day
Year
In case of emergency, name of a relative we can call if we could not reach you.
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone
Emergency Contact Relationship

Activities

Do you have an occupation?
Do you volunteer?
Are you a student

Medical History

Please give us a brief history of your hearing loss. (Please do not include abbreviations or initials when discussion your hearing loss.)
Are you a veteran?
Have you discussed this application with your doctor?
Are you allergic to cats?
Are you allergic to dogs?
Is anyone in your household allergic to dogs?
Please list your height and weight:
Feet
Height Inches
Weight (pounds)
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