First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone*
Cell Phone
What is the best time for us to call you?*
What is the best number we should use to reach you?*
What is your occupation?*
I certify that I am at least 18 years of age.
How did you hear about the Greater Derry Humane Society?*
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
If your home is an apartment or condo, please provide landlord's/condo association's name
Landlord/condo association phone
Is your yard fenced* Choose one: No Yard Unfenced Yard Fenced Yard
What is the height of the fence
Please describe your yard*
Does your current residence have stairs? If yes, how many sets of stairs?*
Are you the only person living in your home? *
Please list the adults that live in your home, their age, and their relationship to you:*
Do children visit your home? *
Please list the ages and how often children visit in the space below:
I understand that I may have a home visit by GDHS prior to hosting a foster animal.* Choose one: Yes
What pets are currently in your household? Please list type of animal, gender, age, and breed of each:*
If you have had pets in your household in the past 5 years that are no longer with you, please list type of animal, gender, age, and why they are no longer with you.*
Veterinarian's Name*
Please provide your veterinarian's address.
Veterinarian's Phone Number*
How many hours will your foster dog be alone at home each day? *
Where will your foster dog be when you are not at home?*
Where will your foster dog be when you are at home?*
Where will your foster dog sleep at night? *
Who will be the primary caregiver of your foster dog?*
Does the primary caregiver have any previous dog experience?*
If yes, please explain:
Do you currently have a vehicle?*
Would you be willing to drive your foster animal to veterinary appointments?*
Would you be willing to meet with potential adopters to discuss information regarding your foster animal?*
Would you be comfortable giving your foster animal medications? *
Are there any limits to the amount of time you can foster? (Yes or No) If yes please provide time limit.*
Are there any size limitations, personality traits, etc. that you would not consider in a foster dog?*
When are you available to start fostering?*
Are you interested in providing hospice (foster/hospice) care to terminally ill dogs?*
Is there anything else you would like us to know about you?
Please list the name and phone number for two references*
By typing my first and last name below, I certify that the information I have given is true and I recognize that any misrepresentation may result in rejection of my application. This serves as my legal signature, and authorizes The Greater Derry Humane Society to verify all information provided.*
Today's Date (mm/dd/yyyy)*