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| *1. | Please complete the following:
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| 2. | Please list a secondary phone if applicable.
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| *3. | Do you own or rent your home?
Own Rent
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| *4. | What kind of home do you live in?
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| *5. | If you rent, do you have your landlord's permission to foster?
Yes No
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| *6. | Can you keep foster cats/kittens in a single indoor room, separate from the rest of your household?
Yes No
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| 7. | If yes, please describe:
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| *8. | Are you available to make regular trips to our facility that is closest to you (either Springfield or Leverett) for supplies, medical attention, etc. (possibly 1-2 times weekly)?
Yes No
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| Please provide the following information about your household: |
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| 9. | How many adults?
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| 10. | How many children?
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| 11. | Ages of children:
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| *12. | Do all members of the household wish to foster animals for DPVHS?
Yes No
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| *13. | Do any members of your household have allergies to animals?
Yes No
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| 14. | If yes, how do you cope with this?
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| *15. | Do you have any pets now?
Yes No
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| 16. | Please list any pets you have in your household and include name, type of animal, age, sex, and whether they are spayed or neutered.
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| 17. | If you have pets, who is your veterinarian?
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| Please Note: Foster animals will be treated by the DPVHS Veterinary Staff. |
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| *18. | Are your pets' immunizations current?
Yes No
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| General Information: |
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| *19. | Have you ever administered medication to a dog or a cat?
Yes No
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| 20. | Please list any special skills/interests you have that would help you as a foster parent:
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| *21. | Please indicate which animals you are able to foster:
Please make at least one selection from the choices below
Adult Cat(s)
Kitten (single or pair)
Kitten (litter)
Bottlefed kittens (require 24hr/day care)
Nursing cat w/litter
Bird(s)
Adult Dog(s)
Small animals: rabbits, guinea pigs, hamsters, rats, ferrets, etc.
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| *22. | Please read the following statement and sign in the box below:
As a volunteer with the Dakin Pioneer Valley Humane Society, I understand the risks involved in working near or with any animal, including the risk of personal injury. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify and hold harmless the Dakin Pioneer Valley Humane Society, its agents, servants and employees from any and all claims, causes of action, or demands, of any nature or cause, including costs and attorney's fees incurred by the Dakin Pioneer Valley Humane Society in connection with the same, based on damages or injuries which may be incurred, or sustained by me in any way connected with my services for the Dakin Pioneer Valley Humane Society, including, but not limited to, animal bites, accidents or injuries.
If you agree with the above statement, please type your name in the box (must be 18 years of age or older to sign)
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By submitting this form, you are certifying that the information you have given on this application is true.
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