Foster Care Application

Humane Society of Independence County

Individual or Couple: *	Individual Couple
Applicant's First Name: *
Applicant's Last Name: *
Primary Mobile Phone: Please use the following format 870-555-5555.
Home Phone: Please use the following format 870-555-5555.
Primary Work Phone: Please use the following format 870-555-5555.
Primary Email Address: * Please enter correctly as this is the main way we will contact you.
Primary Driver's License No
Secondary First Name: *
Secondary Last Name: *
Secondary Phone:
Secondary Email:
Secondary Driver's License No
Street Address: *
City: *
State: *	AR AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code: *
	I own my home. There are no local ordinances preventing me from bringing cats or dogs into my home.
	I rent my home and am permitted to bring an animal or animals into my dwelling.
If you rent, please enter Landlord's contact information:
Including yourself, how many people live in your household?
Please list the ages of those who live in your home.
Personal References (Please, no immediate family member or current household resident. HSIC does contact references, so you references should be told to expect a call from a HSIC representative.
First Reference Name:
First Reference Phone:
First Reference City/State:
First Reference Relationship:
First Reference Length of Acquaintance:
Second Reference Name:
Second Reference Phone:
Second Reference City/State:
Second Reference Relationship:
Second Reference Length of Acquaintance:
Home many pets are currently in your home?
Personal Pet Information (include a separate sheet if necessary).
First Pet Name:
First Pet Age:
First Pet Species (dog, cat, etc):
First Pet Breed:
First Pet Size:	Small Medium Large
First Pet Sex:	Male Female
First Pet Spay/Neutered?	NoYes
What immunizations has this pet had?
Second Pet Name:
Second Pet Age:
Second Pet Species:
Second Pet Breed:
Second Pet Size:	Small Medium Large
Second Pet Sex:	Male Female
Second Pet Spay/Neutered?	NoYes
What immunizations has this pet had?
Third Pet Name:
Third Pet Age:
Third Pet Species:
Third Pet Breed:
Third Pet Size:	Small Medium Large
Third Pet Sex:	Male Female
Third Pet Spay/Neutered?	NoYes
What immunizations has this pet had?
Fourth Pet Name:
Fourth Pet Age:
Fourth Pet Species:
Fourth Pet Breed:
Fourth Pet Size:	Small Medium Large
Fourth Pet Sex:	Male Female
Fourth Pet Spay/Neutered?	NoYes
What Immunizations has this pet had?
Veterinarian's Name: If you have never owned a pet please tell us where you would go.
Veterinarian's Address, City, State, and Zip Code: Again if you have never owned a pet please list where you would go
Veterinarian's Phone Number:
I hereby authorize the above-identified veterinarian to release records to HSIC.
Signature with mouse or finger.	Clear
What kind of animal(s) are you prepared to foster?
	Mother cat with kittens
	Mother dog with puppies
	Litter of orphaned kittens
	Litter of orphaned puppies
	Kitten
	Cat
	Puppy
	Dog
Do you have any experience training and working with dogs or cats?	NoYes
Describe Experience:
Please sign with mouse or finger.	Clear

By signing, I affirm that:
- I am 21 years of age or over and the information contained on this form is true to the best of by knowledge. I make this statement under penalty of perjury under the laws of the state of Arkansas.
- I give permission to Humane Society of Independence County to verify any of the information given, which includes contacting personal references and veterinarian.
- I give permission to Humane Society of Independence County for a Shelter representative to visit my home for a home inspection before my foster application is approved, as well as during my foster time.
- I have read and understand the "Foster Care Agreement" below, which is a separate document from this "Foster Care Application".
- I understand that I could be required to provide foster care to my foster animal(s) for an extended or indefinite period of time. I agree that that period covered by this agreement is the entire time during which I have custody of my foster animal.
- I understand that the foster care coordinators may approve or deny my acceptance into this program based on this or other information.

FOSTER CARE AGREEMENT

Contained herein is a Foster Care Agreement that is entered into by the Humane Society of Independence County, including all employees, herein referred to as Shelter/Foster Coordinator, and the Foster Parent(s). This document is a separate document from the Foster Care Application and must be filled out every time an animal is fostered out and for each animal individually.

- I understand that I am financially responsible for all proper and routine veterinary care, if not brought to the Shelter, including, but not limited to vaccinations and dewormer.
- I agree that if other veterinary arrangements are considered, I will obtain approval from the Shelter/Foster Coordinator before the appointment is made. I also agree to provide documentation to the Shelter/Foster Coordinator within 2 business days.
- I understand that while the animal is in my care, I am responsible for any and all purchases made for the benefit of the foster animal, including but not limited to, bedding, bottles and formula, unless approved in advance by the Shelter/Foster Coordinator.
- I understand that the Shelter provides no guarantee as to the health of my foster animals and that my foster animal may have significant medical needs, socialization problems, and may not be housebroken.
- I will not arrange, pay for, or otherwise cause, the sterilization (spay or neuter) of my foster animal while it is in my care, without express written consent of an authorized Shelter representative or his/her designate.
- I will not arrange, pay for, or otherwise cause, any elective veterinary procedure to be performed on my foster animal while it is in my care, without express written consent of an authorized Shelter representative or his/her designate.
- I understand that I only have my foster animal temporarily.
- I agree that I am fostering this animal for the Shelter and that I do not have any right of ownership over my foster animal. I further agree that the Shelter rights in and to my foster animal are superior to mine.
- I agree to immediately return my foster animal at the request of the authorized Shelter representative or his/her designate, at any time and for any reason. If the Shelter is forced to undertake any action to enforce this provision of the agreement, I agree to indemnify Shelter for any and all court costs and attorney fees connected with such an action.
- If I am planning to move at any time during the period covered by this agreement, I agree to contact the Shelter/Foster Coordinator or other authorized Shelter representative prior to my move, with new contact information. I understand that the Shelter has the right to request the return of my foster animal to the Shelter immediately upon request.
- I understand that because the provisions of this agreement are legally binding, any violation of this agreement could result in legal liabilities for myself and the Shelter.
- If at any point I can no longer, or do not want to continue to provide care, shelter or veterinary care for my foster animal, I agree to contact the Shelter/Foster Coordinator, authorized Shelter representative, or his/her designate, and arrange for surrender and return of my foster animal back to the Shelter. Upon its return, I agree to fill out a surrender form.
- I will not transfer possession or custody of my foster animal to any other person at any time, except for temporary, short-term possession for the purpose of veterinary care, grooming, etc.
- I agree to contact the Shelter/Foster Coordinator or authorized Shelter representative with any and all questions or concerns about my foster animal or the fostering program, as well as with updated contact information, should that change from what is contained in this application. I also agree to contact the Shelter with health updates.
- I agree that if I refuse to comply with any provision of this agreement, the Shelter has the right to terminate this agreement and also has the right to immediate surrender and return of my foster animal and any other animals for whom I am providing foster care for the Shelter. I further consent to provide the Shelter with access to my premises if necessary to facilitate the return.