Beck's Place Form - Foster Boarding Application

Case Status:*
Case Type:*
Beck's Place changes the way families are served. The Foster Boarding Program is a unique and innovative program that cares for pets while families access services that will allow them to achieve stability.
Tell Us About Yourself
Name*

First NameLast Name
Pronoun
Date of Birth

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email Address*
If you do not have an email address, please use none@none.com
Alternate Email Address
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Zip Code*
County*
We currently provide services to people who live in Snohomish County or are receiving services in Snohomish County.
Are you in a domestic violence situation where the current safety of you, your family and/or your pet(s) are at risk?*

YesNo
Are you currently working with a Service Provider?*

YesNo
Which Service Provider are you working with?
Reason for Boarding:

Housing IssuesMedical IssuesFinancial IssuesLegal IssuesSubstance AbuseDomestic ViolenceOther
You selected "Other" above. Please specify:
**We are able to provide care for up to 90 days, extensions can be made on a case by case basis and are subject to foster availability.**
Knowing how long we are able to provide care, what is the estimated boarding time frame?*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Email*
example@example.com
Who is your current veterinarian? *
Are you okay if your veterinarian releases your pet's records to us?*

YesNo
The following questions are optional. The information you provide will be used for grant funding purposes.
Ethnicity/Race

American Indian or Alaska Native‎AsianBlack or African AmericanHispanic, Latino, or Spanish‎Middle Eastern or North African‎Native Hawaiian or other Pacific Islander‎White‎Other Race/Ethnicity
Have you been diagnosed with any physical or mental disability or impairment?

Yes, I have a disability.No, I do not have a disability.
Gender
Household Information
Are you homeless?*

Yes, I'm homeless.No, I am not homeless.
How many people live in your home? *
If you are not the only person within your household, how many of those in your home are under the age of 18? *
What is your monthly household income? *
Tell Us About Your Pets

Our program only allows for a 2-pet maximum per owner household.
Pet Name*
Type*
Age*
Weight*
Gender*
**You have either selected that your pet is not spayed/neutered or "Unknown". If accepted into Pet Assist, they will be spayed/neutered free of cost to you.**
Breed*
Color / Patterning
Add a photo of your pet

Cancelof
Medical Event
Has your pet been vaccinated?

YesNo
What vaccine has your pet had?
Who administered the vaccine?
Date this vaccine was administered.

MonthDayYear
Date
Are there any other vaccines this pet has had?

YesNoUnknown
List any other vaccines your pet has had below.
Does your pet get along with dogs?*

YesNoUnknown
Please explain your pet's history with dogs including temperament, any aggression or fight history.
Does your pet get along with cats?*

YesNoUnknown
Please explain your pet's history with cats including temperament, any aggression or fight history.
Does your pet get along with kids?*

YesNoUnknown
Please explain your pet's history with children including appropriate ages and any positive/negative reactions or aggression.
Has your pet ever bit someone?

YesNoUnknown
Please explain the situation in which the bite occurred.
Do you have a second pet?*

YesNo
Second Pet's Name*
Type*
Age*
Weight*
Gender*
**You have either selected that your pet is not spayed/neutered or "Unknown". If accepted into Pet Assist, they will be spayed/neutered free of cost to you.**
Breed*
Color / Patterning
Add a photo of your pet

Cancelof
Medical Event
Has your pet been vaccinated?

YesNo
What vaccine has your pet had?
Who administered the vaccine?
Date this vaccine was administered.

MonthDayYear
Date
Are there any other vaccines this pet has had?

YesNoUnknown
List any other vaccines your pet has had below.
Does your pet get along with dogs?*

YesNoUnknown
Please explain your pet's history with dogs including temperament, any aggression or fight history.
Does your pet get along with cats?*

YesNoUnknown
Please explain your pet's history with cats including temperament, any aggression or fight history.
Does your pet get along with kids?*

YesNoUnknown
Please explain your pet's history with children including appropriate ages and any positive/negative reactions or aggression.
Has your pet ever bit someone?

YesNoUnknown
Please explain the situation in which the bite occurred.
Final Information
Affidavit For Qualification For Low-Income Services

Income received from all sources in the household on an annual basis must be less than or equal to the amount provided in the chart below. By submitting this form you understand that Beck's Place is unable to provide services to households that are not at or below these qualifications.
Please read and acknowledge the terms and conditions as well as the following Abandonment of Animal, Animal Placement, Vaccination, Veterinary Care, and Spay & Neuter Clauses.
By checking the boxes, you are acknowledging and agreeing to the following clauses:

I certify that I am the legal owner of the animal(s) listed above and the information herein is accurate to the best of my knowledge. I agree to waive any claims against Beck's Place for loss or damages to said animal(s), due diligence, and care having been exercised. It is agreed to by me that the liability of Beck's Place shall in no circumstances exceed the current value of an animal of the same species. I give Beck's Place and its agents permission to care for said animal/s and understand that I am solely responsible for any damage or harm caused to or by said animal(s) that I own. I agree that in entrusting said animal(s) to Beck's Place and their agents that they have relied on my representation that said animal(s) are in good health and have not harmed or shown aggressive behavior toward any person or animal except as otherwise indicated in this form. I, the owner, have read and understand the terms set above. I agree to abide by all terms, conditions, and statements of this agreement.Abandonment of Animal Clause: I understand that, in accordance with RCW 16.54.010, my animal will be considered abandoned if I do not pick up the animal by the "Pick Up Date" date noted above and/or if I have not made approved arrangements with Beck's Place to extend the pick-up date for my animal wherein we mutually agree Beck's Place will continue to provide boarding and animal services as indicated in this agreement. If no pick-up date is established in the original agreement the default pick-up date will be 30 days from the date the animal entered into foster care with Beck's Place. The animal will be considered abandoned if the animal is not picked up and removed from Beck's Place foster boarding program within 15 days after notice to remove the animal has been given to the owner. I understand that as an abandoned animal, Beck's Place will rehome the animal in accordance with state and local laws.Animal Placement Clause: I understand that Beck's Place provides boarding via a network of dog kennels and volunteer foster homes. I do not get to choose where my animal is placed. Beck's Place will board my animal based on availability and a match of the animal's needs with the foster facility or home.Vaccination Clause: Proof of vaccination is required for the Foster Boarding Program. I understand that if I do not have proof of vaccination my animal will be required to receive vaccines in order to be boarded by Beck's Place. If I do not have proof of vaccination I authorize Beck's Place to bring my animals as listed in this boarding agreement to a licensed veterinarian to receive vaccinations as listed in the Vaccination Information section above. Proof of vaccination is required for the Foster Boarding Program. I understand that if I do not have proof of vaccination my animal will be required to receive vaccines in order to be boarded by Beck's Place. If I do not have proof of vaccination I authorize Beck's Place to bring my animals as listed in this boarding agreement to a licensed veterinarian to receive the required vaccinations: For dogs - Rabies, DHPP, Bordetella, and Leptospirosis For cats - Rabies and FVRCP.Veterinary Care Clause: I understand that my animal may become injured or ill and require treatment while in Beck's Place Foster Boarding Program. I understand that if that is the case, Beck's Place will consult a vet of their choice and is authorized to make medical decisions for my animal on my behalf. Beck's Place will make a reasonable effort to consult me on all vet care but I understand that in an emergency that may not be possible.Spay & Neuter Clause: I understand that it is a requirement for my pet to be spayed or neutered to receive services at Beck's Place. If my pet is not spayed/neutered I give consent for Beck's Place to arrange for spay/neuter services with a veterinarian or spay/neuter clinic of their choice.
How did you hear about Beck's Place?
Please verify that you are human*
Should be Empty:

Tell Us About Yourself

Household Information

Tell Us About Your Pets

Final Information