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Foster Application and Contract
Humane Society of the Delta
P O Box 3218
West Helena AR 72390
(870) 753-2119
info@humanesocietyofthedelta.org
Name (first and last) *
Your answer
Date *
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DD
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YYYY
Address: (street, city, state, zip *
Your answer
Home Phone: *
Your answer
Cell Phone: *
Your answer
Email Address: *
Your answer
APPLICATION MUST BE COMPLETED IN ITS ENTIRETY
Employed: *
Place of Employment: (address, city, state, work phone, position and length of employment) *
Your answer
Current Pets: (please list name, type of animal, and age) *
Your answer
Former Pets: (please list name, type, breed, age, what happened to them, and year *
Your answer
If you rent, please provide your landlord's name and phone number *
Your answer
Is there extra security deposit for pets? If so how much? *
Your answer
Whom do you live with? Please check any that apply. *
Required
Number of children and ages *
Your answer
Are any family member allergic to pets? *
If anyone if your household is allergic to pets, please explain who is allergic and what is the allergy to? *
Your answer
Where will this pet spend the day? *
How many hours a day will the pet be alone? *
Where will the pet spend the night? *
How do you plan to confine this pet to your property? *
Your answer
Who will have primary care of this pet? *
Your answer
Who will care for this pet when you leave for vacation? *
Your answer
How do you plan to exercise this pet? *
Your answer
Name, address and phone number of current or former veterinarian. (A veterinarian's reference is the fastest way to get an approval, please call them immediately and give them permission to speak to us.) *
Your answer
If you currently have a pet, is it current on all vaccinations? *
If you currently have a pet, are you using a flea and tick preventative? *
If you don't use a veterinarian currently, please submit three non-family references. (name, phone number relation) *
Your answer
PLEASE BE ADVISED THAT YOU ARE SIGNING A LEGAL, BINDING CONTRACT
You may not sell, give away, or abandon this animal. Please return this animal to the Humane Society of the Delta in the event that you are unable to care for it, for any reason. YOUR RESPONSIBILITIES INCLUDE: Provide food, water, and shelter at all times. Obey local, state and federal laws regarding testing, vaccinations, and sterilization. Cooperate with follow-up efforts of the Humane Society of the Delta. Absolve, released and hold harmless the Humane Society of the Delta any responsibility for damage to person or property, cost or expense caused by the animal.
Signature: (type name) *
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