Hollis Center, Maine 04042

(207)727-3408

Name____________________________________Tel._____________________Date_________

Street____________________________________City____________________State/Zip_______

Employer__________________________________________Work Telephone_______________

Employer(spouse)___________________________________Work Telephone_______________

E-mail address:____________________________________

Please list pets you now have in your home.

Would your pets accept a new dog? Yes______No________

Have you had pets in the past? Yes_________No_________ If so, please describe:____________

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Do you own_____or rent______; a house_____, apartment_____, or condo______? If renting, please give landlord's name, address, and phone number. We require the landlord's consent for your having a dog.

Landlord's Name_____________________________________Street______________________

City___________________________State_______________Telephone____________________

Do you have a securely fenced yard? Yes_____No______How high?_______ If not, are you willing to fence, install a pen/run, or leash-walk at all times? Yes_____No____

How many adults are in your household?________Children?________Ages of children.___________

Do you have contact with grandchildren or neighborhood/other children? Yes______No________

What are the working hours of the adults in the house?_____________________________________

Does anyone in the house have allergies? Yes_____No______

Please describe the activity level of the house - busy, in and out a lot, or a more quiet, structure atmosphere?____________________________________________________________________

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Where will the dog be kept during the day?_____________________________________________

Where will it sleep at night?_________________________________________________________

Where will it be kept when left alone?_________________________________________________

Where and how will the dog be exercised?_____________________________________________

How many hours per day will the dog be left alone?______________________________________

Cockers vary greatly in temperament, personality, and activity level. What characteristics would you find undeserable in a foster cocker?__________________________________________________

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Would you accept a dog that is older? yes___no___; has been abused? yes____no____; is not reliable with children? yes____no____; has a physical handicap? yes___no___; is pregnant and whelping? yes____no____; is recovering from medical treatment and may need foster care for 2 to 4 months? yes____no____.

Please describe any experience you have had in training and/or rehabilitation work with dogs.________

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Some rescue cockers have problems with separation anxiety, fearfulness or dominant behavior. Would you be willing to help retrain a dog following a specific behavioral remediation program that includes support from a trained professional? yes______no______

If necessary, would you be willing to take a foster dog to obedience training (at MCSR's expense) or to obedience train him/her yourself? yes___no___

If you now hav a pet, is it up-to-date on its shots and heartworm test and on heartworm preventative? yes___no___

Veterinarian's name_____________________________Street__________________________

City___________________________State__________________Tel.___________________

I understand that MCSR, Inc. will be responsible for any medical, training, or other approved expense associated with the foster dog in my care.

I understand that by signing this form, I agree to release and covenant to hold harmless MCSR, Inc. and its members from any claims, damages, costs or actions incurred as a result of the foster care or actions of the foster dog.

I will notify MCSR immediately should the foster dog become lost, stolen, seriously ill or die. The foster dog will wear a MCSR ID tag at all times.

I understand that should I decide to permanently adopt the MCSR foster dog in my care, I will pay MCSR the adoption fee to help defray the costs of spaying, neutering, shots, heartworm test and other medical expenses that have been incurred by MCSR. The adotpion fees are as follows:

$200.00 dog up to 1 year of age

$150.00 dogs age 1 through 8 years of age

$50.00 for dogs age 9 years and older

I certify that I am at least 21 years of age and that I will be solely responsible for the care and well-being of any dog tha I foster care for MCSR.

Any misrepresentation of the true facts in this foster home application will invalidate the foster home agreement and will give MCSR the right to immediately reclaim the foster dog.

Signature___________________________________________________Date_______________