Foster Application Form

How did you hear about Pennington County Humane Society

Full Name*

First NameLast Name

Age

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number - Home

Area CodePhone Number

Phone Number - Cellular

Area CodePhone Number

Phone Number - Work

Area CodePhone Number

Do you live in a:

Do you:

OwnRentLive with ParentsOther

If Renting: Please indicate landlord contact information

Household Setting

RuralSuburbanUrban

Describe your Homes Activity Level

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

Does Anyone in your Household have Allergies to Animals?

YesNo

Are all members of your Family agreeable to Fostering an animal?

YesNo

Please List any Pets you have (Please include Name, Breed, Age, Altered, Sex, UTD Vaccines, Heartworm,)*

Do you have a preference in sex of foster?

MaleFemaleNo Preference

Are you willing to foster a animal of any age?

YesNo

If not, what age would you consider?

Please describe the type of animal you are willing to foster (Please include species, breed, coat length, personality traits, energy level, hypoallergenic) We always want to make sure we have the best fit for our foster homes.

Are you willing to take your foster animal to vet appointments at a convenient time for you?

YesNo

Do you drive or have access to a vehicle to bring your foster to events and appointments

YesNo

If No please explain

Are you willing and able to medicate your foster animal?

YesNo

We cannot guarantee a foster animal will be housetrained, are you equipped to train with love and patience?

YesNo

Have you had any experience with with an emotionally or physically neglected or abused animal?

YesNo

If Yes please explain

Are you willing to use a crate for a animal if recommended?

YesNo

Do you have a fenced yard?

YesNoPartial

If fenced, please give details on height, material, # of gates, are gates locked or lockable?

How many hours in a day would the foster be left alone?

What are you plans to exercise your foster? Please list any parks near by or trails, how many walks a day, approximate length, and activities such as agility.

Please list a references with name, address, phone numbers are you ok with this?

YesNo

Reference: Full Name

First NameLast Name

Relation to applicant(s):

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehended it fully.

I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any Pennington County Humane Society animal I fostered.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless Pennington County Humane Society and it's members from any claims, damages, costs, or actions incurred because of the care or actions of the foster dog.

I accept full responsibility for the animal 's actions at all times and release Pennington County Humane Society from any liabilities or damages that may be incurred because of fostering such animal(s).

I agree to have the Pennington County Humane Society complete reference call checks and they may conduct a home visit inspection to approve my foster application.

I agree that if I'm unable to foster the animal(s) anymore, I will return the animals to Pennington County Humane Society and give Pennington County Humane Society a 2-week period to try and find another suitable foster for the animals(s).

PARTICIPANT RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT (READ CAREFULLY BEFORE SIGNING)

In consideration of executing this Participant Release and Waiver of Liability and Indemnity Agreement (this “Release and Waiver”) and participating in any way in the PENNINGTON COUNTY HUMANE SOCIETY Pet Adoption & Wellness Center (“PENNINGTON COUNTY HUMANE SOCIETY”) Foster Volunteer Program, now or at any time in the future (each participation an “Event” or “Events”), I, for myself, my personal representatives, heirs and next of kin agree to the following.

REPRESENTATIONS AND WARRANTIES

I acknowledge and represent that: (1) I am at least 18 years of age; (2) I have agreed to participate in one or more Events after careful consideration of the risks that may be associated with the Events and have agreed to undergo all of the training necessary and associated with fostering an animal from PENNINGTON COUNTY HUMANE SOCIETY; (3) I understand that animals, even under the best of circumstances, may be unpredictable, may bite or scratch and may transmit zoonotic disease and I certify that I am in good health and I have no conditions or impairments which would preclude my safe participation in volunteering at an Event, including that I am current on all medical vaccinations, including but not limited to tetanus, or that I have made the decision to not vaccinate myself and understand the risks associated with that decision; (4) I understand that I, family, visitors, and other persons exposed to the foster animal (collectively, “Exposed Persons”) may be interacting with the foster animal and this could present certain risks to those Exposed Persons; (5) I understand that if I have existing pet(s) in my home and even if I quarantine or separate a foster animal from my pet(s) that illnesses may spread to my pet(s) despite my best efforts; (6) I warrant that I will agree to assume full financial responsibility for any and all damages to, or losses of, the real or personal property of PENNINGTON COUNTY HUMANE SOCIETY or any third party caused directly or indirectly, in whole or in party, whether or not foreseeable, by myself, as determined by PENNINGTON COUNTY HUMANE SOCIETY in its sole and absolute discretion, and I further agree to indemnify and hold harmless the Released Parties from any third-party claims related thereto; and (7) I understand that my participation in any Events may be revoked or suspended at any time for non-compliance or safety issues, as may be determined by PENNINGTON COUNTY HUMANE SOCIETY in its sole discretion.

I acknowledge and fully understand that my participation may involve risk of serious injury or death to myself or Exposed Persons, including losses which may result not only from my own actions, inactions, or negligence but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the Event or activity is being conducted, and/or the rules of play of this type of Event or activity. Such risks include, but are in no way limited to, (1) slips, trips, and falls, (2) dog, cat, or other animal bites or scratches, (3) athletic injuries, and (4) illness, including exposure to and infection with viruses or bacteria. I further acknowledge that the preceding list is not exhaustive of all possible risks associated with volunteer participation and that it in no way limits the operation of this Release and Waiver. My own actions or inactions may cause such risks and dangers. I also acknowledge that any injuries I may sustain may be compounded or increased by negligent or delayed rescue operations or procedures of the Released Parties (as hereinafter defined). I further acknowledge there may be other risks and economic losses, which may be known to me or may be unforeseeable, that are presented by my participation in any Event held by PENNINGTON COUNTY HUMANE SOCIETY. I understand that if I have any risk concerns, I should discuss these concerns with the activity coordinators and Event staff before signing this document and before participating in any activity or event.

WAIVER, RELEASE, INDEMNIFICATION & COVENANT NOT TO SUE

I further agree to indemnify, save and hold harmless PENNINGTON COUNTY HUMANE SOCIETY, its officers, directors, employees, volunteers, agents, representatives and insurers (the “Released Parties”) from any and all claims, causes of action, demands, losses, damages, and liabilities for indemnities, contribution or otherwise arising from my participation in an Event, which I, my heirs, representatives, executors, administrators, and assigns may have, now or in the future, with respect to any personal injury, property damage, death or accident of any kind, arising out of or in any way related to an Event, whether that participation is supervised or unsupervised. However, the injury or damage occurs, including but not limited to the negligence of the Released Parties. I further agree to indemnify, save and hold harmless the Released Parties from any and all claims, causes of action, demands, losses, damages, and liabilities for indemnities, contribution or otherwise arising from an Exposed Person. I acknowledge and agree that this Release and Waiver is intended to be, and is, a complete release of any responsibility of the Released Parties for any and all personal injuries, temporary or permanent disability, death, and/or property damage sustained by myself while on the property or in any way related to the Event activities, including those of an Exposed Person, and is intended to be as broad and inclusive as is permitted by the laws of the State of Minnesota and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

RIGHT TO USE PHOTOGRAPHS, VIDEO, AND IMAGES

I understand that public relations is an essential part of the activities conducted at PENNINGTON COUNTY HUMANE SOCIETY. I hereby authorize PENNINGTON COUNTY HUMANE SOCIETY to use, without notice or compensation, the likeness of myself in any and all social media, photographs, video and images, and to further include my name in any materials that promote PENNINGTON COUNTY HUMANE SOCIETY's services and programs, or to publicize any event, or for any other lawful purpose (including but not limited to, the right to edit, alter, copy, publish or distribute). I understand and agree that all film, prints and negatives become the sole property of PENNINGTON COUNTY HUMANE SOCIETY and may be used by PENNINGTON COUNTY HUMANE SOCIETY without payment or royalties or any other consideration or prior notification. This Release and Waiver will be governed by and interpreted in accordance with the laws of the State of Minnesota. I agree that any action arising out of this an Event or this Release and Waiver must be brought exclusively in any state or federal court located in Minnesota. If any provision of this Release and Waiver is deemed invalid, void or unenforceable, such provision shall be considered severed from this Release and Waiver and the remaining provisions shall be given full force and effect. No change, modification, amendment, or addition of or to this Release and Waiver shall be valid unless in writing and signed by PENNINGTON COUNTY HUMANE SOCIETY’s President and Chief Executive Officer. This Release shall be binding upon and inure to the benefit of the successors, assigns, and legal representatives of the parties.

I HAVE READ AND VOLUNTARILY SIGN THIS WAIVER AND RELEASE AND DO SO WITH THE UNDERSTANDING THAT SUBSTANTIAL RIGHTS ARE BEING GIVEN UP. I UNDERSTAND THAT MY PARTICIPATION IN THIS EVENT IS VOLUNTARY, AND RELEASING THE RELEASED PARTIES IS PART OF THE CONSIDERATION

Your name*

E-mail

Signature

Date

MonthDayYear