Foster Care Application

Foster Care Application

Personal Data NAME _____________________________________________________________ ADDRESS __________________________________________________________ CITY _____________________ STATE ___________ ZIP ___________________ PHONE (day) ____________________ (evening) ___________________________ OVER 18 YRS. OF AGE ____________ SOCIAL SECURITY # ______________ (If no, parent or guardian must also sign application – page 3)

REFERENCES Please list three references and their telephone numbers. Name _______________________________________ Phone # _________________ Name _______________________________________ Phone # _________________ Name _______________________________________ Phone # _________________

HOUSEHOLD INFORMATION Living Accommodations

Rent

Own

Does your lease allow pets?

Yes

No

Other __________

Landlord’s name _____________________________ Phone # _________________ Do you have a securely fenced in yard?

Yes

No

Do you have screens on your windows?

Yes

No

How many children at home? ____________ What are there ages? ____________ Have you handled animals before?

Yes

No

PERSONAL PET INFORMATION Do you have any pets now?

Name

Yes

Breed

No

Sex

How many? _______

Spayed/Neutered

Age

Please list your current veterinarian’s name __________________________________ Current veterinarian’s phone # ____________________________________________ Do your pets have any behavioral problems or chronic illness?

Yes

No

Explain: _______________________________________________________________ Are your pet’s immunizations current?

Yes

No

Where do your pet’s stay? ________________________________________________

If you have no pet’s now, have you had pets before?

Yes

No

If yes, where are they now? ________________________________________________

How much time do you devote to your pet on a daily basis? _____________________

GENERAL INFORMATION How did you hear about the Foster Care Program? ___________________________

Would you permit a Humane Society Foster Program Representative to visit your home? Yes No Have you ever administered medication to a dog or cat before?

Yes

No

What pet supplies do you have? (crate, litterpan, etc.) _________________________

FOSTER INFORMATION How many days/weeks can you foster an animal? ______________________________ How much time daily would you have for your foster animal? ___________________

Describe area where foster animal will be housed and cared for: ________________

How will you segregate the foster animals from your own pet? __________________

What are the care arrangements when you are not home? ______________________

What behavior are you unwilling to work with? ______________________________

Have you ever been convicted of Animal Neglect, Cruelty or Abandonment? Yes No What kind of animal(s) are you prepared to foster? (Please circle all that apply) Injured/ill adult cats Injured/ill kittens Mother and kittens Litter of orphaned kittens

Injured/ill adult dogs Injured/ill puppies Mother with puppies Litter of orphaned puppies

I give permission to the Fluvanna SPCA to verify any of the information given. ______________________________________ Volunteer Signature

______________________ Date

______________________________________ Parent/Guardian

______________________ Date