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 Other __________

Does your lease allow pets? Yes No

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? Yes No How many? _______

Name Breed Sex 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 adult dogs

Injured/ill kittens Injured/ill puppies
Mother and kittens Mother with puppies
Litter of orphaned kittens Litter of orphaned puppies

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

______________________________________ ______________________
Volunteer Signature Date

______________________________________ ______________________
Parent/Guardian Date