Heartworm Foster to Adopt Application

2. Name of dog you are interested in fostering*

4. First Name*

5. Last Name*

7. Email Address*

8. Daytime Phone*

9. Alternate Phone

11. Address1*

13. Address2

15. City*

16. State*

17. Zip*

19. Describe Yourself - your interests, your job, your favorite activities, etc.:*

21. Please list the names and ages of anyone in your extended family or friends with whom a fostered animal will frequently come in contact. Include name, relationship, age, gender, and frequency of contact:*

23. Do you currently own another pet or pets? If so, how are they doing? (List type of animals, breed, names, ages and sex, spayed/neutered or not? and a brief description of their personality.)*

25. Veterinarian to contact for vaccine history*

27. Housing

    1. I own my home.
    2. I rent my home.

28. Landlord

    Please list your landlord's name.

29. Landlord's daytime phone number

31. Fencing*

    1. My yard is fenced.
    2. I don't have a fenced yard.

    A fenced yard is recommended for dogs however it is not required.

33. Do you understand that heartworm treatment dogs will need to be kept indoors with periods of limited activity?*

    1. Yes
    2. No

34. Do you have the ability to accommodate these needs?*

    1. Yes
    2. No

36. This pet will need to visit the shelter on a weekday once a month for treatment. Please describe your typical schedule and if you would be able to commit to bringing this dog for appointments.*

38. Agreement*

    I understand that if I am approved for fostering, I will be given a treatment schedule and instructions for my foster dog. I will also be required to sign a contract detailing my commitment to caring for a heartworm positive dog before I take my foster dog home.
    
    

    1. I understand
40. Acknowledgement*

    I have read this Application in its entirety, and I agree that all statements contained in this document are made by me, and are truthful. I make this statement under penalty of perjury under the laws of the state(s) of North Carolina.
    
    

    1. I agree
42. Thank you!
    We appreciate your interest in being part of our Heartworm Foster to Adopt Program.

    We appreciate your interest in being part of our Heartworm Foster to Adopt Program.

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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field