Please complete this application form if you are interested in becoming a Humane Society of Portage County foster care giver. Once you complete the form, click the submit button at the bottom.

Name and address

First name:

Last name:

Middle name:

Street 1:

Street 2:

City:

State:

* Zip: *

Home phone:

OK to call me here

Work phone:

OK to call me here

Cell phone:

OK to call me here

Email address:

Spouse's name:

Check if we can send you a text message:

Demographic Information

You may optionally provide the following information. It is used only to help us get a better idea of the demographic make-up of our volunteers.

Date of birth:

Gender:

Education:

Rent or own?:

Do you have transportation?:

Drivers License Number:

List ages of all children in household:

How often do you travel?:

If you rent, please provide landlord name and contact information.

Residence

Please describe your residence. Check all items that apply.

Fenced in yard:

Secure screens on all windows:

Room available to isolate foster animal:

Other things we should know:

Employer / Employment

Please tell us about your current employment. What are your normal working hours? Do you travel for work?

Employer name:

Other adults in your household

Please tell us about other adults (18 years old or older) living in the household (do not include the applicant name)

1

2

First name:

Last name:

Birthdate:

3

4

First name:

Last name:

Birthdate:

Current pets

Are all pets spayed/neutered?:

Are all pets current on vaccinations?:

List each pet in your home (name, species, breed, age, sex) How do they react to other animals? How do they react to stressful situations such as change in daily routine?

Vaccination verification

We will need to verify your pet's vaccination status for both your animal and our foster animal's protection. Please provide your veterinarian clinic name and phone number.

Disclosure

Have you ever been convicted of any law violation (except minor traffic violations)? Yes or No

If yes, please provide details.

Please note: Disclosure of a criminal record will not necessarily disqualify you from volunteering for the Humane Society. However, failure to disclose such information may result in disqualification of your application or termination of your volunteer service.

Volunteer Experience

Please describe any volunteer experience you have at HSPC and when you volunteered (month/year).

Availability

My availability is:

From:

to: