First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

How often do you check email?*
Choose one: More then once a day Once a day Every couple of days Weekly - not often

Date of Birth (NOTE: YOU MUST BE 25 YEARS OR OLDER TO ADOPT/FOSTER)*

Occupation*

Marital Status*

Spouse/Significant Other's Name*

Spouse/Significant Other's Date of Birth*

Spouse's Occupation*

How many people reside in your household*

Do you have any children in your household OR children that visit you- and if yes, what are their ages?*

Please list everyone that resides in your home *

Does anyone in your household smoke? *

Does anyone in your household have allergies to animals? *

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

Please provide your Landlord's contact information (Name/Phone #)

Do you have a fenced yard?*
Choose one: Yes No

What type of fence
Choose all that apply: Privacy Chain Link Invisible

What is the height of the fence*

Who in the household will care for the pet*

Please describe all pets currently with you (age, sex, altered status, BREEDS, WEIGHTS. Please note - If you have a current pet or pets, they must be up to date on vaccinations and spayed/neutered. This includes cats. Dogs must have annual vet exams.) *

Please describe pets that are no longer with you (type, sex), and what happened to them. *

Have you ever given up a pet? If yes, please explain*

Veterinarian contact information: *

What name are the vet records under?*

How much time will the animal spend alone during the day*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are not home*

Where will the animal be kept when you are home*

Do you have a way to go home during the workday and check on the dog? *
Choose one: Yes No

Where will the animal sleep*

Why are you interested in fostering a dog?*

Please give us some information on your home

Are you ready to foster a dog immediately? If not, when?*

Do you have a time limit on fostering a dog? If yes, how long?*

Do you have any dog training experience? (Housetraining, Crate training, Obedience?) Please explain *

The majority of dogs that come into rescue are not housetrained and will have accidents. How do you plan on dealing with that?*

Is there any type of dog that you would not consider fostering (e.g., breeds, sex, behaviors)? If so, please explain*

What personality traits are you looking for in a foster dog?
Choose all that apply: Male Female Baby Young Adult Companion Protective Companion for Another Pet Long Hair Short Hair

If your other animals do not get along with your foster dog do you have a way to separate them when you are not at home?*
Choose one: Yes No

How else would you handle a problem between your animals and your foster dog?*

Are you aware we require a home visit prior to fostering a dog?*
Choose one: Yes No

Is there any other information that you feel would be important for us to know about you or your living situation?

Please list two personal references (non-relative), Name, Address, Phone Number: *

Please list one personal reference (relative), Name, Address, Phone Number: *

By checking YES, you understand that Pixie Mamas Rescue has the right to either deny or approve your application without explanation. A denial is not a rejection of you as a person; it is a refusal to place a pet in a situation that we do not feel is a good match or does not meet our policies. *
Choose one: Yes No

By checking YES, you understand and agree that you are not allowed to adopt your first 2 foster dogs and that Pixie Mamas Rescue does not allow foster to adopt for first time fosters.

I certify that the information entered on this applicant is true. Enter your name and date*

Pixie Mamas Rescue welcomes all volunteers and most appreciates your time and effort. However, we must caution you that working with stray and abandoned animals carry risks. We cannot predict the temperament of any dog and cannot guarantee you that the dog may not become aggressive. Therefore, you must understand that you are assuming certain risks if you agree to work directly with the dogs. We want you to understand and acknowledge the potential risks before deciding in which volunteer activities you would like to participate. I have accurately completed this questionnaire and have read the above warning and appreciate the risks involved in working with the dogs. I understand that PMR cannot be responsible for the actions, behavior and/or medical condition of all of the dogs which it seeks to rescue and I agree to assume the risks involved with working with dogs who may have been abandoned, beaten, or otherwise mistreated or abused, or who may suffer from an illness, condition or disease. By submitting this form, you are removing Pixie Mamas Rescue from any liability. Pixie Mamas Rescue remains the owner the foster dog until it is adopted and may reclaim it any time seen fit from the foster home *

By checking this box, you give Pixie Mamas Rescue permission to schedule a home visit with the animal of your interest, and upon doing so, you acknowledge that as the Premises of the Owner or Occupier, our animals, guests, items and activities thereon, could pose dangers to people and other animals. Such dangers include, by way of example and not limitation, animals that can bite, trip, knock down, and fight, persons who cannot control their dogs, and activities involving dogs/cats that can result in injury from bites or other causes. Accordingly on behalf of the PMR representative, the Owner or Occupier or his/her spouse and minor children, and anyone else who is on the Premises of the Owner or Occupier, (a) waives any and all legal duties on the part of PMR and assumes the risk of injuries, losses, damages, costs and expenses by any means above described, and other injuries, losses, damages, costs and expenses of every possible cause and description unless inflicted intentionally or recklessly by the agents and employees of Owner or Occupier.