Foster Care Application

General*

Please provide 2 references, to include full name and telephone number where the person may be reached.
Reference 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Reference 2*

First NameLast Name
Phone Number*

Area CodePhone Number
*

I agree to a home visit at a mutually agreed upon time by a YCHS staff member or representative.I agree to return the following items which have been loaned to me by the YCHS, upon completion of the foster period.I agree to submit to a criminal history check should the YCHS request it.
I understand the terms of this contract and agree that it is in the best interest of the animal(s). I will abide by all of the conditions stipulated. I hereby agree to indemnify and hold harmless, the Yancey County Humane Society, its employees, volunteers and agents from any and all liability arising out of or in conesequence of injury sustained as a result of any activity connected with fostering of any animal(s) from the YCHS is the sole property of the YCHS.
Signature of Foster Caregiver*
Printed Name*

First NameLast Name
Date*

MonthDayYear
Date
FOR OFFICIAL USE ONLY
Approved

YesNo
Date

MonthDayYear
Date
Signature
Comments:
Should be Empty:

FOR OFFICIAL USE ONLY