PLEASE NOTE:

Adoptions at our Pieloch Pet Adoption Center will be by appointment only to follow recommendations from local and national health authorities regarding social distancing. To make an appointment please call our Pieloch Pet Adoption Center at (402) 441-4488 ext 1. Our Admissions & Assessment Center is open but is only allowing one customer/party in the building, at a time. Please be patient, as our staff works to assist you. We ask for visitors to please wear a mask and practice social distancing when visiting either of our locations.

Foster Care Application

Name (Required)

Address (Required)

Apt

City (Required)

State (Required)

Zip (Required)

Driver's License # (Required)

State (Required)

Employer (Required)

Daytime Phone # (Required)

Evening Home # (Required)

Email Address (Required)

*majority of communication will be through email*

Do you live in a...

Condo/Townhouse
Apartment
Duplex
Mobile Home/House

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Do you...

Rent/Lease
Own your residence

Name and Phone Number of Landlord/Owner (Required)

How long have you been at this address? (Required)

How many adults reside in the household? (Required)

Are there any children in your home?

Ages (if selected yes above)

Have you ever turned an animal over to an animal shelter

If yes, what were the circumstances?

Do you have any pets at home now?

(Pet 1) Name, Breed, Age, Sex

(Pet 2) Name, Breed, Age, Sex

(Pet 3) Name, Breed, Age, Sex

(Pet 4) Name, Breed, Age, Sex

Are your pets current on vaccinations and licensed?

*If no, they must be before fostering.*

What Animal Hospital/Vet Clinic do you (or did you) use? (Required)

Approximate date and reason for last vet visit? (Required)

Would there be anyone home during the day?

Has anyone in the household ever had allergies to animals?

What supplies would you need the shelter to provide for you to do foster care? (Required)

*The shelter does provide all supplies needed.*

Is there room in your home where you can keep foster animals confined separate from your own?

If yes, describe

Do you have a fenced yard?

What are you interested in fostering?

Kittens with Mom
Adult Cat
Puppies with Mom
Adult Dog
Kittens
Puppies
Other animals

Other animals willing to take?

List two references (people who know you and your ability to care for pets):

1. Reference Name (Required)

1. Reference Phone (Required)

2. Reference Name (Required)

2. Reference Phone (Required)

Please list pets you have owned in the last 5 years

1. Name

Cat/Dog

Breed

Age

2. Name

Cat/Dog

Breed

Age

3. Additional pets

How did you hear about the foster care program? (Required)

I agree that all the information which I have given the Capital Humane Society is correct. (Required)

*please enter name*

If you have any questions, please contact:

Chrissy Mattox & Sierra Kurth

Community Programs Coordinators

Capital Humane Society

(402)477-3270 & (402) 441-4482

foster@capitalhumanesociety.org