^{1935 - 20th Ave SE   .   Minot, ND 58701   .   Phone 701-839-6116   .   FAX 701-838-7622}

Foster Home Application

This questionnaire must be completed by any individual who is interested in providing foster care.  The information provided by you will help to ensure that the placement is in the best interest of both you and the pet. Please return this form to the Souris Valley Humane Society via e-mail or mail.

Date: ____________________________

Name: _____________________________________________________ Age: ________

           First                                                         MI         Last

Street Address: __________________________________________________________

City/State/Zip: __________________________________________________________

Mailing Address (if different): ______________________________________________________________________

Phone Numbers:    Day ___________________________________________________

Evening ________________________________________________

What type(s) of pet(s) would you like to care for?     Cat      Dog      Horse     Bird    Other

Number of pets you are able to care for? ____________________

Please check any of the below which would apply to the care of foster pets in your home:

Cat

    Would be kept strictly indoors.

    Would not be permitted in the house.

    Would be restricted to the following areas:__________________________________

Dog

    Would be kept indoors and taken outside for walks on a leash.

        Would be kept indoors and have periodic access to fenced in yard.

        Would only be outside under supervision.

        Would be kept strictly outdoors:    Chained     Fenced in yard     Kennel (dimensions _______)

        Would be confined within the house.  Please describe the area in which the pet will be confined:_____________________________________________________________

____________________________________________________________________

How many hours per day would the pet be left alone? _______________________________________________________________________

Are there any restrictions as to the size or type of pet you could foster? ________________________________________________________________________

Where will the pet sleep at night? ________________________________________________________________________

What length of time would you be willing to keep a foster pet? ________________________________________________________________________

Are you able to bath/groom the foster pet on a regular basis?                                    

    Yes      No

Do you have any objections to a Humane Society representative visiting your home?            

If the foster pet should become ill, will you contact the Humane Society immediately?           

    Yes     No  

Would you notify the Humane Society if the pet should become lost?                          

   Yes      No         

Would you be able to transport the pet to a veterinarian?                                           

    Yes      No

Would you like financial assistance to meet the food/litter needs of your foster pet?    

    Yes      No

Would you be agreeable to the owner visiting the pet with proper notice?                             

    Yes      No

Would you be willing to contact the owner, on occasion, to keep him/her updated on the pet? 

    Yes      No

Please list the type of pets you currently own:

Species                     Breed                                       Age        Sex     Spayed/Neutered

______________   ________________________   ______  _______       Yes      No

______________   ________________________   ______  _______       Yes       No

______________   ________________________   ______  _______       Yes       No

______________   ________________________   ______  _______        Yes       No

______________   ________________________   ______  _______        Yes       No

______________   ________________________   ______  _______        Yes       No

______________   ________________________   ______  _______        Yes       No

Who is your regular veterinarian? _________________________________________________________

If you do not currently own a pet, please describe your prior experience with pet ownership: ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Number of adults in your household: __________________________________________

Number of children and their ages: ___________________________________________

Is any member of your family allergic to pets?    Yes    No    

If yes, please explain _______________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Are there any concerns with a family member that needs to be considered in regard to the type

of animal you foster (i.e. physical disability or limitations)? ____________________________

_______________________________________________________________________

Do you own or rent your home?  ______________________________________________

If you rent, provide landlords name, address, and phone numbers: ________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I attest, by signing, that the above information is accurate and true to the best of my knowledge.

_____________________________________________      _________________________

Name                                                                                                               Date

_____________________________________________      _________________________

Address                                                                                                           Phone Number(s)

_____________________________________________      _________________________

City, State and Zip Code                                                                                  Driver’s License Number