Name: ___________________________________________________________

Email: _______________________________________________

Address: ______________________________________________________________________

______________________________________________________________________

Birthdate: ____________ (you must be 18 or older)

Home Phone: _________________________________ Work Phone: _____________________

Please list your veterinarian and two (2) personal non-related references. We will contact them while reviewing your foster partner application.

Veterinarian: __________________________ Phone: ______________________

Address: _______________________________________________________

Reference 1: ________________________________________ Relationship to you: ____________________

Address: _________________________________________________ Phone: _____________________

Reference 2: ________________________________________ Relationship to you: ____________________

Address: ________________________________________________ Phone: _________________

To help us match animals with partners, please let us know about your preferences in fostering. You may, of course, change these preferences at any time.

What type of animal would you be interested in fostering? ______cat ______dog

If a dog is your choice,

what age is preferred? _____ puppy _____ dog _____ older dog

what size is preferred? _____ small (less that 20 pounds)

_____ average (20-50 pounds)

_____ large (50-89 pounds)

_____ very large (90+ pounds)

is a particular breed preferred? _______________________________________

is a particular breed not acceptable? ___________________________________

If a cat is your choice,

what age is preferred? _____ kitten _____ cat

The foster animals have been seen by a vet and have received their rabies and DHLPP vaccinations. Dogs over 1 year old have tested negative for heartworm; cats have tested negative for feline leukemia. While we cannot guarantee the health of the animals, every reasonable effort has been made to ensure it.

I hereby authorize our veterinarian, as well as the two references listed above, to disclose medical and character information to a representative of DCFOA.

By signing below, I release and waive any right against the Dearborn County Friends of Animals, Inc., its employees and volunteers for any damage caused by any foster animal to persons or property now or in the future and accept possession of any foster animals at my own risk.

Foster Applicant Signature: ____________________________________ Date: ________________