Household Information

Full Name of Applicant

Full Name of Spouse/Other Household Adult Involved in Adoption

Street Address:

Mailing Address:

City State Zip Code

Town City Village of: County:

Home Phone How long have you lived at above address? Months Years

If less than 3 years, previous address:

Email address

This residence is a    House Apartment Condo Mobile Home Farm Other   

If Other, please explain

Do you   Rent Own Land Contract Live with parents/relatives/friends Other

If Other, please explain

If owned, under whose name is property listed?

If rental or mobile home park, you must list landlord/owner’s name/address/phone #

Applicant's Date of Birth  Other Adult's Date of Birth

EMPLOYER(S)

Applicant Phone #

Spouse/Other  Phone #

HOUSEHOLD

How many adults in household?         Children?           Ages

Do all adults agree on fostering a pet?          Yes  No           If no, why not?

Is anyone in the household allergic to animals?           Yes    No             If yes, what type of animals and how severe is the allergy?

In some cases, candidates for foster care may have bacterial, viral, or fungal infections, or may have mobility issues resulting in an animal that is more "underfoot".   Does any person in your household have special  needs, or any condition, such as a compromised immune system, that might be affected?  Yes    No

Will this be your first experience with a pet?  Yes   No     

Who will be responsible for the care of the pet?

Approximately how many hours per day will the pet be left alone?          

What pets do you currently have in your household?

PLEASE LIST BELOW ALL PETS OWNED IN THE PAST 5 YEARS OTHER THAN THE ABOVE:

Name/address or phone number of past & present veterinarians:

Do any animals currently in your household have special needs, illnesses, or conditions that may impact the animals' immune system?  If so, please explain.

In many cases, foster animals will need to be kept isolated from other animals in the household.  Where will you keep your foster animal(s), and if necessary, how will they be separated from your current animals?

How did you hear about us?    Visited Before Adopted Before Newspaper Radio Word of Mouth PetFinder Other Internet Other If other, please tell us how:

Please list a non-related individual who could verify that you are a responsible, caring pet owner.

Name    Phone 

Have you ever taken any animal to a shelter?             Yes   No             If yes, please explain:

Have you previously  adopted  or redeemed a pet from an animal shelter?    Yes   No           Year         (note:  redeemed means to claim your lost animal).

Name/location of shelter  

Are you familiar with the following?  (Please check all that apply)

Distemper (Panleukopenia)        Feline Leukemia (FeLV)        Feline immunodeficiency virus (FIV)    Feline infectious peritonitis (FIP)       

Heartworm    Bordetella

Are you willing to work with us to make arrangements for a member of our staff to visit your home (if necessary) prior to fostering or during your foster period in order to evaluate suitability of your home for special needs animals, check progress of your foster animals, assist with medical needs, or take photos for publicity or adoption purposes?Yes    No

Our candidates for foster care often have very specific special needs.  For example, a candidate for foster care may require additional exercise or a reduced activity level due to a medical condition, or due to socialization issues may not be ready for a household with frequent visitors.  The following questions are not only to help us in determining whether you would be a match for our foster program, but also to determine what animals/situations would be most suitable for you, and what assistance you will require from us.  Please understand that in most cases, there is no wrong answer to these questions.  

Why are you interested in fostering?  Please check all that apply.

I would like a pet, but am not ready or able to make a lifetime commitment at this time.

I would like to help special needs animals from my own home.

I would like my children to see the miracle of birth.

I would like a family pet that I have raised from birth.

I am interested in learning more about handling special needs or training and behavior modification.

I am interested in adopting a special needs animal but would like to make sure I can handle the special needs prior to adoption.

Other reasons (please explain)

Approximately how much time per day do you have available to care for your foster animals?

Approximately how long do you plan for your foster commitment to last?        Days    Weeks   Months  Permanent (if all works out)  Other 

What kind of animals are you interested in fostering?  Please check all that apply.

Special needs dogs (medical)    Special needs dogs (behavioral)    Dogs needing socialization    Pregnant/nursing dogs with litters       Orphaned/young puppies   

 Special needs cats (medical)       cats needing socialization/extra attention    Pregnant/nursing cats with litters      Orphaned/young kittens

guinea pigs        rabbits           ferrets           other small animals     birds           reptiles           farm animals 

Please specify any information on types of animals you are interested in and/or  specific types of special needs.

Are you comfortable with (or willing to learn)    administering medication       bottle feeding      basic grooming needs    special medical care (e.g. injuries, newborn care)

Please tell us about any other frequent visitors to the household (for example, grandchildren, additional children you may care for, friends or family members who frequently visit or stay.

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  If you are interested in fostering dogs, please complete this section:

 Are you comfortable working with dogs who need behavior modification or obedience training?  Yes    No

 Do you have experience in obedience training dogs?  Yes    No

If so, what?

 Do you know the difference between positive and negative reinforcers?  Yes    No

If so, please define or give examples.

Do you know the difference between positive and negative punishers?  Yes    No

If so, pleases define or give examples.

Do you use leash corrections, body rolls or any other form of physical punishment?Yes    No

Do you have experience in behavior modification in dogs?  Yes    No

If so, what kind of experience?

Are you willing to take instruction on behavior modification and obedience training protocol?Yes    No

 Are you willing to bring your foster dog to the shelter on a regular basis to have behavior modification sessions with a trained staff member?  Yes    No     Could you come (please check those that apply)  Daily   Every other day   Weekly   Every two weeks   Monthly

How do you plan to provide physical exercise for your foster dog (check all that apply)?     Walking on a leash     Loose in fenced yard       Tied out in yard      Swimming       Playing "Fetch"    Other (please specify)        On average, how much time per day do you plan to exercise your dog? 

 Are you willing to provide mental stimulation for your foster dog through appropriate games or activities?  Yes    No

 Are you willing to keep accurate documentation of the foster dog’s progress?  Yes    No

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If you are interested in fostering cats, please complete this section:

If interested in orphaned kittens or kittens requiring supplementation, how often would you be able to give bottles each day?     every 2 hours   every 4 hours     every 6 hours     every 8 hours    

Are you willing and able to give a foster cat time to adjust, and to keep your foster cat confined to a kennel if necessary during the adjustment?  Yes   No

Are you willing and able to bring your foster cats and/or kittens to the shelter or veterinarian as needed for any necessary immunizations or care? (In some, but not all cases, this care may be provided in your home) Yes   No

Are you willing to provide weekly updates by phone or email on your foster cats, and to contact a shelter representative immediately in case of problems, or events such as the birth of kittens?  Yes    No

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Do you have any questions, or is there anything else you would like to tell us about yourself or your family?

WE WILL NOT KNOWINGLY PLACE A PET IN A SITUATION WHERE ITS WELL-BEING IS QUESTIONABLE.  THEREFORE, WE RESERVE THE RIGHT TO REFUSE ANY APPLICATION.  NO PET WILL BE PLACED WITH APPLICANTS WHO MISLEAD OR FAIL TO PROVIDE COMPLETE AND ACCURATE INFORMATION ON THIS APPLICATION.