1. Today's Date:

     MM/DD/YYYY

    

2. Please provide the following contact information:

   * First Name
   * Last Name
   Middle Initial
   Spouse's Name	(if applicable)
   Name of Employer	(if applicable)
   * Street Address
   Address (cont.)
   * City
   * State/Province
   Zip/Postal Code
   * Country
   * Home Phone
   Work Phone	(optional)
   FAX	(if applicable)
   * E-mail

    

3. Is this a family membership?

   Yes
   No
   N/A

    
4. Your Age (Note: If under 18 you must have a guardian's consent):

   * Age

    

5. Please check what your interests are and tell us about your experiences?  What areas would you like to help the BCCR in?   (check all that apply):

   Fundraising
   Membership & adoption interviews / homechecks
   Transport
   Mail outs / Phone
   Research / Marketing
   Website support of database maintenance
   Resource contact for shelters and/or other rescue organizations
   Public relations and advertising
   Add to email mailing list
   N/A - add to email mailing list only
   Other - please let us know below

   Other comments or thoughts on helping the BCCR:

    

    

6. Can we contact you when we are in need of help?

    
   
    

7. Do you want to be notified of BCCR events?

   Yes
   No
   N/A
   
   

8.  Do you support spaying and neutering of pets?

   Yes
   No

    

9. Please provide breed, sex, age, and name of your dogs (and/or other pets):

    

    

10. Are your pets up-to-date on their shots?

    Yes
    No - please explain why below:

     

     

11. Are your pets spayed / neutered?

    Yes
    No - please explain why below:

     

     

12. Have you ever bred your pets?

    No
    Yes - please explain why below:
    
     
    
     

13. Have you had any previous pets? If so, what happened to them?

     
    
     

14. Name of Veterinarian (must be provided, if you have pets):

    Name
    Title
    Organization
    Work Phone
    E-mail

     

15. * Personal Reference 1:

    Name
    Relationship
    Home Phone
    E-mail

     

16. * Personal Reference 2:

    Name
    Relationship
    Home Phone
    E-mail

     

17. What Humane Society or SPCA are you located near and do you have an established relationship with them?

    
    

18. Do you work with any other rescue groups or animal related organizations who we can contact for a reference?  If so, please list group(s) and contact information.  Do we have permission to contact them?:

     
     

     

19. Finally, please tell us why you would like to become a member of the BCCR?  Would you be open to fostering in the future?  Feel free to share any additional thoughts with us here.
     

     

IMPORTANT INFORMATION - PLEASE READ:

TERMS AND CONDITIONS

I, the undersigned, hereby certify that I am of legal age (older than 18) and that all statements made herein make full disclosure and are true. Should there be any change in the circumstances as stated above, I undertake to notify BCCR as soon as possible. 

I also understand that by submitting this application that I and the members of my household agree to the BCCR Code of Ethics (click here to read BCCR COE - Adobe pdf format).

I verify my understanding and acceptance of the above terms and conditions.

     Yes
    No

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