1. How did you hear of WI Cocker Rescue?

2. Name Telephone Fax

3. Address

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

4. Employer Work #

5. Employer (spouse) Work #

6. Email address

7. Please list all pets you currently have in your home:

Breed: Gender: Neutered:Yes No Age: Owned Since:
Breed: Gender: Neutered:Yes No Age: Owned Since:
Breed: Gender: Neutered:Yes No Age: Owned Since:
Breed: Gender: Neutered:Yes No Age: Owned Since:
Breed: Gender: Neutered:Yes No Age: Owned Since:

8. Would your pets accept a new dog? Yes No

9. Have you had pets in the past? Yes No

10. If so, please describe

11. If you now have a pet, is it up-to-date on vaccines, HW test, and HW preventive? Yes No

12. IMPORTANT: If you have owned a pet within the past five years, please fill out the following information.

Veterinarian's Name/Clinic

Address

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

Telephone Fax Email

FOSTER FAMILY PERSONAL INFORMATION

13. IMPORTANT. Please list two personal references:

Name Relationship Day Tel. Evening Tel.

Name Relationship Day Tel. Evening Tel.

14. Do you: Rent Own
House
Apartment
Condo

15. IMPORTANT. If renting, please provide landlord's name, address and telephone number. We require the landlord's written consent for your having a dog. Please include this consent when you return this application or your Adoption Application will not be processed.

Landlord's name Telephone

Address

City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

16. List members of your household.

Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:

17. Do you have much contact with grandchildren or other children? Yes No

18. What are the working hours of the adults in the house?

19. Does anyone in the house have allergies? Yes No

20. Please describe the activity level of your home:

Busy - visits by friends, meetings, children, parties at home
Noisy - TV, stereo, machinery, tools, children playing, dogs barking
Moderate - normal comings and goings
Quiet - "homebodies," few guests

CARING FOR YOUR FOSTER COCKER

21. Where will the dog be kept during the day?

22. Where will it sleep at night?

23. Where will it be kept when left alone?

24. Where and how will the dog be exercised?

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

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

27. Would you accept a dog...(please answer Yes or No to each category)

a. that is older? Yes No
b. that has been abused? Yes No
c. that is not reliable with children? Yes No
d. that has a physical handicap? Yes No
e. that is pregnant and will be whelping? Yes No
f. that may need foster care for 2-4 months? Yes No

28. Are you willing to continue the dog on a special diet and medications? Yes No

29. Do you have a securely fenced yard? Yes No

30. If so, how high is the fence?

31. If not, are you willing to fence, install a pen or run, or leash walk at all times?

Yes (please specify)
No

TRAINING YOUR FOSTER COCKER

32. Please describe any experience you have had training and/or rehabilitating dogs.

33. Some rescued Cockers have separation anxiety, fearfulness or dominant behavior. Would you be willing to help retrain a dog following a specific behavioral modification program that included support from a trained professional? Yes No

34. If necessary, would you be willing to take a foster dog to obedience training or to obedience train him yourself? Yes No

FOSTER CARE RESPONSIBILITIES

I understand that WI Cocker Rescue will be responsible for any medical, training, or other approved expenses associated with the foster dog in my care. Yes No

I understand that by signing this form, I agree to release and covenant to hold harmless WI Cocker Rescue and its members from any claims, damages, costs, or actions incurred as a result of the foster care or actions of the foster dog. Yes No

I will provide compassionate and loving care for my foster Cocker until he has been successfully placed in a permanent home. This care includes adequate food, water, shelter, and medication (when required). Yes No

Some of the WI Cocker Rescue Cockers are fed a natural diet while in rescue. If you foster one of these Cockers would you agree to continue this type of diet? Yes No

I will be patient and tolerant during the transition period and am prepared to work with my foster Cocker on basic training such as housebreaking and leash training. Yes No

I will notify WI Cocker Rescue immediately should the foster dog become lost, stolen, seriously ill or die. Yes No

I will work cooperatively with WI Cocker Rescue to find the foster Cocker a permanent, loving home as quickly as possible. I understand that prospective adopters may wish to visit the Cocker(s) before adopting them. I am willing to allow prospective adopters to meet the Cocker(s) either at my home or at a mutually convenient location. Yes No

I understand that should I decide within the first 30 days of foster care to permanently adopt the WI Cocker Rescue foster Cocker in my care, I will pay WI Cocker Rescue the adoption fee to help defray the costs of spaying, neutering, shots, heartworm test and other medical expenses that have been incurred by WI Cocker Rescue. Yes No

The adoption fees are as follows: