I Want to Foster

Midland County Pit Stop Foster Application

* Indicates required field

Date *

Foster Applicant Information

Name: First, Middle, and Last *

Birthdate *

Physical Address *

City *

State *

Zipcode *

Most Recent Previous Address *

City *

State *

Zipcode *

Day Phone *

Cell Phone *

Email *

References

Please provide three references who are not considered family or living with you.

First and Last Name *

Phone Number *

First and Last Name *

Phone Number *

First and Last Name *

Phone Number *

Current/Previous Pet Info

Have you ever owned a dog or cat? *

Do you currently have pets? *

Yes No

Type/Breed/Name/Age/ Veterinarian/Spay/Neuter/UTD *

Home/Family Information

Number of adults living in your household? *

Number of children in your household? *

Spouse/Roommate's Name (First, Middle, and Last) *

I give Midland County Pit Stop permission to do background checks on all adults in the home. ******PLEASE INITIAL****** *

Birthdate of Spouse/Roommate(s) living in the house *

Do you rent or own? *

Rent Own

If you rent, please list your landlord's first and last name *

Landlord's Phone Number *

Which best describes the area you live in? *

City Suburb Rural

How long have you lived at this address? *

Do you have a yard *

Yes No

Is it fenced? If so, how high is the fence? *

Other - please specify *

In the event the main caretaker is unable to care for the foster pet, Midland County Pit Stop should be contacted to make other arrangements. **** PLEASE INITIAL **** *

Date *

Do any of your household members suffer from pet dander related allergies? *

Yes No

Does the foster pet need to be *

Dog friendly Cat friendly Child friendly

Are there any specific breeds, weight limits or sizes you prefer to foster? *

Care Plan

Comment *

If you do not have other pets, how will you socialize the foster pet? *

How many hours a day will the foster pet be alone? *

Where will the foster pet stay when no one is home? *

Where will the foster pet stay when you are home? *

Will this pet be kept *

Indoor Outdoor Both

When going out of town or on vacation, Midland County Pit Stop must be given notice in advance to make arrangements for the foster pet. ** PLEASE INITIAL ** *

Date *

Home visits are required prior to foster approval and placement by a foster liaison. ** PLEASE INITIAL ** *

Date *

Veterinary Care

Where will you vet your foster pet? *

Are your current pets on preventatives? *

Yes No

Tell us about your experience with pets

Comment *

.** If for any reason you are unable to care for the foster animal, contact Midland County Pit Stop. *

** PERSONAL OR PROPERTY DAMAGE AND/OR INJURY** I acknowledge and agree that if the animal bites or causes other injuries to humans and other animal , I will not hold Midland County Pit Stop of Midland Michigan responsible. I understand that all animals can carry and transmit diseases, including zoonotic diseases that can be transferred from animals to humans. I understand that Midland County Pit Stop will not be responsible for any damage the foster pet may inflict on another person, another animal or any property, or for the transmission or transfer of any disease or parasite to other animals or people in the household. No attempt(s) will be made by me or anyone on my behalf to hold Midland County Pit Stop responsible.. I hereby release Midland County Pit Stop and its agents, representatives/liaisons, and volunteers and agree to indemnify and hold same harmless from any and all actions, causes of action, suits, debts, dues, accounts. covenants, agreements, judgements, claims and demand of any nature whatsoever arising out of my foster pet from Midland County Pit Stop. I understand that if I am approved as a foster to a pet, I must abide by this agreement and that this agreement applies to any and all dogs/cats that I foster from Midland County Pit Stop. ********************PLEASE INITIAL******************** *

Date *

** Signature will be required upon approval of application **

Approved By (Midland County Pit Stop Foster Liaison) *

Date *

Submit

Date

APPROVED BY (Midland County Pit Stop Liason)