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?:

     

Information specific to fostering:

19. Tell us about your household and why you choose to foster a Chihuahua:

20. Are you willing to permit a home check by a BCCR representative?

Yes
No

22. Do you have any long range plans within the next year that might affect your ability to foster? 

23. Your preference is to foster?

Female
Male
Either

24. What age are you willing to foster (choose all that apply)?

Puppy
Adult
Senior
Any

25. Are you willing to foster an animal that has special needs? (health, diet, training, other)

Yes
No

If yes, any problems not accepted?

26. Are you prepared to keep the foster dog for an indefinite period of time, until the dog can be placed into an approved home?

Yes
No 

27. Are you aware that you must provide safety to both the rescue while in your care, and you are responsible for his/her behavior while in your care?

Yes
No 

28. Are you aware that you need to seek approval from the directors prior to any medical care with the exception of emergency care and that you must provide receipts?

Yes
No 

29. Do you understand that you will be asked to take part in your foster dog’s adoption and required to interview any suitable adoption applications?

Yes
No
 

30. Do you understand that should you find a suitable adoption applicant that you must submit the application along with your recommendations for acceptance to the directors of the BCCR?

    Yes
    No
     

31. Your Residence (check all that apply):

    Own
    Rent
    Single Family Home
    Apt/Condo
    Townhome
    Mobile Home
    Trailer/RV
    Farm
    Other
    
     

32. If renting, do you have permission to keep pets in your home?  Can you obtain a letter stating this?

 

33. Do you have home owners insurance?  Will it cover you and your family for fostering?

    Yes
    No

     

34. If fostering, do you agree to do so at your own risk?

    Yes
    No

     

35. Approximate size of the living area:

 

36. Approximate size of fenced area:

     

37. If there is not a fenced yard, will you provide leashed walks:

    Frequently
    Occasionally
    None

     

38. How do you plan to housebreak the dog if it's not already housebroken?

39. Children in your household?  Please provide the number and their ages.  How do they relate to pets? 

40. Other residents - please list the names and ages of all co-habitants or others who frequently share your premises and/or fenced yard:

 

41. Are all members of your household aware that you will be fostering?

    
     

42. Do they all approve of you fostering for the BCCR?

     

43. How many hours a day will the foster(s) be left alone?

44. Where will the dog be kept when alone? (please be specific -  i.e., crate, room, run of house etc).  Include day vs at night and when the family is home.

45. If there is any aspect of your home that a puppy could affect (white carpet, antiques etc) -- please identify:
    
     

 
46. What is the level of activity in your household (choose all that apply)?

Laid back
Constantly on the run
Physically handicapped
Other, please describe below

47. Are you away for extended periods?

Yes
No

If so, will you:

Board
Hire a sitter
Take the foster with you

48. If you have children in the household, how much of the responsibility will your child be given for the care and management of the dog?

    Maximum
    Some
    Minimal
    None

49. How much adult supervision will be provided when the dog and child are together?

    Maximum
    Some
    Minimal
    None

50. If there are no children in your household, how often will the dog come into contact with children?

    Maximum
    Some
    Minimal
    None

51. How many interactions will the animal have with visitors?

    Maximum
    Some
    Minimal
    None
     

52. Finally, please feel free to share any additional thoughts with us here.  Thank you for applying for our fostercare program. We couldn't help them without you.
     

     

     

    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 (COE) (click here to read BCCR COE - Adobe pdf format).

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

        Yes
        No

      Please enter the number that appears on the left.

      (By submitting this form, you agree to all the above terms and conditions) - Please note any required fields marked with a "*" must be completed before this application will submit.  Write us if you have any problems - info@chirescue.org.

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