Name (please print clearly) :

Address (physical address) :

Address (mailing address) :

City-State-Zip:

Home Phone (with area code) :

Cell Phone (s) (with area code) :

Email address:

Please retype email address:

Do you own or rent your home. Own Rent

Landlord Name - Phone Number :

Living arrangements: Live alone Live with spouse Live with parents / roommate

How many members are there in the household:

If there are children, names and ages:

Emergency contact name :

Contact address (physical address) :

Contact home phone (with area code) :

Contact cell phone (s) (with area code) :

Contact email address:

Please read carefully and answer all questions

Do you have a fenced yard: Yes No

If a pet is placed in a foster situation with you, Cherished Cockers will provide routine and emergency veterinary care through designated veterinarians. Foster dogs are not to be treated by unauthorized veterinarians except in cases of extreme emergency. Expenses resulting from unauthorized routine care will be the responsibility of the foster parent. Do you agree: Yes No

All foster dogs are to be kept indoors only, with adequate food, water and attention. Do you agree to make a commitment to care for the dog until a permanent home can be located. Yes No

Approximately how many hours per day will your foster dog be alone?

Where will the foster dog spend the day while you are away?

Where will the dog sleep?

Do you have the knowledge and time required to housebreak and/or obedience train the pet if the situation should occur that it becomes necessary? Yes No

Do you presently have any animals, if so, please list those currently residing with you (type of animal, age, sex, neutered/spayed, and how long you have owned them: Are they all inside animals? Yes No

Please tell us a little about yourself, and why you would like to foster.

Please provide three references including your present veterinarian, if applicable. Please provide current addresses and telephone numbers for your references. Name: Address: Phone: Name: Address: Phone: Name: Address: Phone:

In consideration of this opportunity to foster, I agree to the following terms and conditions, intending to be legally bound by them: I will furnish a representative of Cherished Cockers the names, addresses and telephone numbers of three veterinarians so Cherished Cockers can set up an account for care. If this is not possible, the foster will be required to submit the required payment or make other arrangements with Cherished Cockers. The foster will submit all invoices to Cherished Cockers within 5 business days. Cherished Cockers will reimburse the foster for the invoices within 5 days of receipt of said invoices. Every Cocker coming in to foster care with Cherished Cockers will be vetted. This will include: Spay/neuter when necessary All applicable vaccinations Heartworm test PLEASE NOTE: If there is an emergency or unforeseen veterinary care is necessary, Cherished Cockers should be notified immediately for approval. You will be provided with contact number of person(s) who can provide approval. If there is a personal emergency, vacation scheduled, etc, please notify Cherished Cockers if arrangements need to be made for the care of the foster. If someone other than the person(s) signing this agreement will be responsible for caring for the foster, please advise Cherished Cockers, in writing, and furnish their contact information. In the event that the foster feels the need to make a purchase for the care of the foster, please notify Cherished Cockers for approval. This should include an estimate for the item(s) requested. I will abide by the mission, rules, regulations, policies and programs of the Cherished Cockers, Inc. while I am a foster. I assume the risks of being bitten, scratched, injured or frightened by dogs and puppies or other Cherished Cockers animals in connection with my foster work for Cherished Cockers. The Cherished Cockers organization, officers and volunteers are not liable to me for any injuries, damages, liabilities, losses, judgments, costs or expenses which I might suffer or sustain in connection to the performance of my foster activities for Cherished Cockers unless they are the result of Cherished Cockers' gross negligence or intentional misconduct. I will indemnify, defend and hold Cherished Cockers harmless from and against any claims, lawsuits, injuries, damages, losses, costs or expenses sustained by any companion animal or any person in connection with my intentional misconduct or grossly negligent performance of foster activities for Cherished Cockers, or my breach of Cherished Cockers' rules, regulations, policies and programs. If I suspend foster activities, or upon Cherished Cockers' request at any time, I will promptly return all Cherished Cockers supplies, equipment, records, monies and other items in good, clean condition. I will not have a person outside Cherished Cockers organization temporarily care for Cherished Cockers' animals (i.e. a visitor, pet sitter, neighbor, relative) unless the person first signs a Hold Harmless Agreement to hold Cherished Cockers, its officers and volunteers harmless in the event of injury or mishap. In the case of an adoption, an Adoption Agreement is to be signed. Any modification to this Agreement must be in writing and signed by both parties. This Agreement is binding upon Cherished Cockers, Cherished Cockers' representatives, me and my respective heirs, successors, assigns, executors and personal representatives. I agree to INDEMNIFY and HOLD HARMLESS Cherished Cockers for any costs or liabilities which they may incur as a result of my fostering for Cherished Cockers. I acknowledge and agree that I have carefully read this Agreement, that I fully understand the same, and that I freely and voluntarily execute the same. I understand that I may seek independent advice prior to signing this Agreement. I understand that this Agreement is binding on me, my spouse, my executors, administrators, personal representatives and assigns and that this Agreement has important legal consequences. The terms of this Agreement are contractual and not mere recitals. This Agreement will be construed in accordance with and governed by the laws of the State of Ohio. I will abide by all the terms stated above and not dispute or take issue with them in any way. Yes No

Signature: (For purposes of this application, printing your name is equivalent to a signature.)

Date: