First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
What is your occupation?*
What species/breed of animal(s) are in willing to foster?* Choose one: Direct Care (Cats) Dog with puppies Cat With Kittens Direct Care (Dogs)
Where did you hear about fostering at Safe Haven of Iowa County?*
Do you currently have/live with any pets? If so, please list the name, species and number of pets you currently own (cat, dog, reptile, barnyard, etc.). If not, please type none.*
What kinds of pets (if any) have you owned/lived with in the past ten years? If none, please type none.*
If you currently have pets, are they spayed or neutered?
If you currently own a pet(s), is your pet(s) up-to-date on vaccinations? Choose one: Yes No
May we contact the above veterinarian for a reference?
What is your veterinarian's name and address? Please list all veterinarians that may have seen your current or previous pet(s) as well as the contact name that your pet(s) would be listed under. If no pets in last 10 years please type n/a.*
What is above veterinarian's telephone number? If no current veterinarian, please type n/a.*
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 own, please select "Own". If you rent, have you received the approval of your landlord to have an animal?* Choose one: Own Yes No
If you own, please enter "Own" or n/a . If you rent, please enter your landlord's name and phone number.*
Is your yard fenced* Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced
What is the height of the fence?
What type of fence is around your yard?* Choose one: Privacy Chain Link Invisible No Fence
Please describe the area in which the animal(s) will be kept.*
How many people reside in your household and in particular, how many children reside with you and what are their ages?*
Does every member of your household wish to participate in our foster care program?* Choose one: Yes No
Can you transport animals you are caring for to and from a Veterinarian for appointments?* Choose one: Yes No
Can a prospective adopter call you regarding a foster pet in your care?* Choose one: Yes No
Can a prospective adopter visit your home to meet a foster pet in your care?* Choose one: Yes No
Have you ever been a foster caregiver for another animal shelter or rescue group? Please provide us with as much information as possible.*
List two references, including phone numbers, of people who are not family members and not your veterinarian. Please also let your references know that our volunteer may be calling them so that our calls are answered.*
Are you willing to allow a representative of Safe Haven of Iowa County to complete an inspection of your premises prior to placing a pet into your home?* Choose one: Yes No
Are you willing to allow a representative of Safe Haven of Iowa County to complete random home inspections throughout the pet's stay?* Choose one: Yes No
Have you, or any other member of your household, ever been arrested, charged or convicted of any animal-related crime such as failure to provide adequate care, animal cruelty, animal abandonment, animal neglect or any crime of moral turpitude?* Choose one: Yes No
Do you, any member of your household or anyone who visits regularly have any pet allergies?* Choose one: Yes No
If your response to the previous question was "YES", please tell us who among your household or regular visitors has allergies and to what types of animals are they allergic?
By selecting "YES", I certify that the information I have given on this adoption application is true and correct and that I recognize that any misrepresentation of the facts submitted herein may result in losing the privilege of adopting or keeping an adopted animal. I understand that Safe Haven of Iowa County has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this application. I understand that this application is the property of Safe Haven of Iowa County.* Choose one: Yes No
Disclosure and Release Clause: I, the undersigned, do hereby declare that I am aware: that animals are different from human beings in their response to human actions; that the actions of animals are often unpredictable; that animals should be closely supervised when they are with children; that an animal's behavior may change after it leaves the shelter and accustoms itself to a home or other different environment; that Safe Haven of Iowa County makes no claims or representations as to the temperament, health or mental disposition of any animal put up for adoption that Safe Haven is not held liable for conditions arising from the adoption of an animal. THE ADOPTING FAMILY DOES HEREBY RELEASE, DISCHARGE AND HOLD HARMLESS SAFE HAVEN of IOWA COUNTY AND ANY PERSON, FIRM OR CORPORATION CHARGED OR CHARGEABLE WITH LIABILITY TOGETHER WITH THEIR HEIRS, ADMINISTRATORS, EXECUTORS, SUCCESSORS AND ASSIGNS FROM ANY AND ALL CLAIMS, DAMAGES, COSTS, EXPENSES, LOSS OF SERVICES, ACTIONS OR CAUSES OF ACTION, WHETHER KNOWN OR UNKNOWN, BELONGING TO THE FAMILY DUE TO ANY ACTION OR OCCURRENCE ARISING OUT OF OR IN CONNECTION WITH THE ADOPTION OF A PET FROM SAFE HAVEN. This animal will be cared for and treated with love and respect. I agree to assume full responsibility for its well-being, including providing adequate and wholesome food, fresh water, shelter from the weather and any veterinary treatment needed to provide continued health and well-being of the animal. Dogs will not be kept on a chain because of the health hazards that may occur, the lack of exercise chains prevent and the potential dangers it may cause such as teasing and being trapped with no escape. Dogs will not be solely used as hunting or guard dogs. Cats will not be used solely as barn cats or mousers. I agree to abide by all city and county animal control ordinances, specifically any leash laws to prevent the animal from roaming and becoming a nuisance animal. It is expressly understood that such animal is NOT to be sold, traded, or given away for any purpose. It is not to be abandoned. It is not to be used for experimentation, resold to a lab or treated in any other inhumane way. If I cannot provide for the animal any longer, I will return it to Safe Haven of Iowa County. Adopter agrees that, without liability, Safe Haven of Iowa County may investigate the adopter’s home and the conditions under which the animal is being kept, and may take possession of the animal, if in the opinion of Safe Have of Iowa County, it is receiving less than adequate care, is being improperly housed or handled, or if any other condition of this contract is being or has been violated. In the event the adopter fails or refuses to return such an animal upon demand, the adopter hereby agrees to pay reasonable attorney’s fees in the event an attorney is consulted or if suit is brought for the return of the animal. The adopter acknowledges reading and understanding all policies within this contract and accepts this animal as a pet and companion, and willfully accepts the terms outlines within this legally binding agreement. Enter your name, to acknowledge reading and agreement with this disclosure. *
I certify that the information entered on this application is true (enter your name and date).*
