Foster Caregiver Application & Agreement - NTSRI
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Foster Caregiver Application & Agreement
You Can Help
Date
Contact Information
Name*
Street Address*
City*
State*
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HI
IA
ID
IL
IN
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KY
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OR
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TN
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UT
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WA
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Zip*
Home Phone*
Work Phone
Cell Phone*
E-Mail Address*
Repeat E-Mail Address*
Name of Employer
Occupation
Household Information
Number and ages of children in household
Type of Residence
House
Apartment
Condo
Do you own or rent your home?
Own
Rent
If renting, do you have landlord's permission to have a pet?
Yes
No
Do you have a fenced yard?
Yes
No
If yes, please describe type and height
If no, how will the dog be exercised and allowed to eliminate?
List other dogs currently in the household, including name, breed, age and whether they are spayed or neutered
What other animals live in your home?
Information Relevant to Foster Care
Do you have a preference as to the sex of the dog?
Yes
No
If yes, which do you prefer and why?
Will the dog live inside your home?
Yes
No
If no, where will it live?
Where will the dog sleep at night and when you are away from home?*
Who will have primary responsibility for care of the dog?*
Do you belelieve in the use of dog crates?
Yes
No
If not, why not?
Have you ever trained a dog in obedience class?
Yes
No
Are you willing to let an NTSRI representative periodically visit your home?
Yes
No
What do you know about the Samoyed breed?*
Why do you want to foster a rescued Samoyed?
Veterinarian Information
Name
Street Address
City
State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Personal References
Please provide the information below for two references who have known you for at least 2 years.
Name
Street Address
City
State
-
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
Name
Street Address
City
State
-
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Terms & Conditions - PLEASE READ CAREFULLY!
Agreement*
THIS AGREEEMENT is entered into with NORTH TEXAS SAMOYED RESCUE, INC. (“NTSRI”), a nonprofit Texas corporation and the person submitting the Agreement, who wishes to be a Foster Caregiver for NTSRI (“Caregiver”). 1. NTSRI shall deliver into the temporary custody of the Caregiver the Samoyed breed dog(s) (“Dog(s)”) agreed upon by the parties. Caregiver shall provide care for the Dog(s), at Caregiver’s address listed on the Application attached hereto and made a part hereof, for an indefinite period of time, subject to the further terms and conditions listed below. It is expressly agreed and understood that all right, title and interest in the Dog(s) remain vested solely in NTSRI, and that Caregiver shall not sell, trade or otherwise relinquish custody of Dog(s) to any animal control agency, humane society, pet shop, medical lab, or owner other than NTSRI. Under no circumstances whatsoever shall Dog(s) be euthanized without the express written permission of NTSRI. The Caregiver shall not, under any circumstances, promise Dog(s) to any person or represent or imply that Caregiver has the authority to approve a prospective adoption. At no time whatsoever shall Caregiver be considered an employee, agent, partner or representative of NTSRI. NTSRI warrants that Dog(s) have been examined by a licensed veterinarian prior to placement with Caregiver, and that Dog(s) are current on vaccinations, including rabies. NTSRI makes no other representations, express or implied, as to Dog(s)’s health or demeanor other than what has been documented by a licensed veterinarian. 2. Caregiver shall provide the following to the Dog(s) throughout the period that the Dog(s) remain in the custody of Caregiver: 2.1 Nutritious kibble dog food (unless health issues require canned food) in amounts appropriate for the age and size of Dog(s) twice daily, morning and evening; 2.2 Clean, accessible water throughout the day; 2.3 Administration of any required prescription medications, including heartworm preventative, as directed by a licensed veterinarian; 2.4 Transportation to and from veterinarians as necessary; 2.5 A clean, dry, safe and climate-controlled indoor location where Dog(s) shall reside at all times, except when Dog(s) need to eliminate or exercise (crate training is acceptable and recommended, provided Dog(s) are not crated for longer than five (5) consecutive hours per day and crates are located indoors); 2.6 Exercise and play sufficient to keep Dog(s) in good physical and mental condition (at no time whatsoever shall Dog(s) be allowed off-leash in an unfenced area); 2.7 Grooming, including keeping the coat clean and brushed and the nails trimmed; 2.8 Socialization of the Dog(s) with humans and other pets; 2.9 Basic obedience training (sit, down, stay, walk on leash); 2.10 Housetraining as needed; 2.11 Evaluation of Dog(s)’s behavioral and personality traits (including but not limited to notation of any aggression issues, biting, overzealous play, fear of objects or persons, etc., which shall be immediately reported to NTSRI.) 3. Caregiver shall use NTSRI’s veterinarian, Love Field Pet Hospital, 6550 Lemmon Avenue, Dallas, TX 75209, (214) 357-0348, for all routine veterinary care, including but not limited to vaccinations, spay/neuter surgery, and treatment of illness or other medical conditions. Prior approval from NTSRI must be obtained for all routine veterinary care, and all charges for such shall be charged to NTSRI’s account for payment directly to the veterinarian by NTSRI. In the event that emergency care is necessary during hours that NTSRI’s veterinarian is unavailable, Caregiver shall transport Dog(s) to the emergency care veterinary facility nearest to the Caregiver’s location for treatment. Caregiver shall notify NTSRI of the need for such emergency care as soon as possible. Where practicable, prior approval from NTSRI shall be obtained for emergency treatment. 4. The following costs and expenses shall be the responsibility of NTSRI: 4.1 Routine veterinary costs and expenses incurred at NTSRI’s veterinarian described in Section 3 above, including heartworm preventative and other prescribed medications, prescription food, spay/neuter surgery and treatment of illness or other medical conditions, provided that Caregiver has received prior permission from NTSRI to incur such costs and expenses. Such costs and expenses shall be paid directly to the veterinarian by NTSRI. 4.2 Emergency veterinary costs and expenses, provided that the reason for the emergency treatment was not the result of negligence, abuse or misconduct on the part of Caregiver. Such costs and expenses shall be paid directly to the emergency care facility where practicable. In the event that the nature of the emergency precludes the possibility of direct billing to NTSRI, reimbursement to Caregiver shall be made only upon NTSRI’s receipt of an itemized statement from the emergency care facility, which details the diagnosis, all procedures and medications administered to Dog(s), and proof of payment by the Caregiver in the form of a cancelled check or credit card receipt. The following costs and expenses shall be the sole responsibility of Caregiver: 4.3 Food, non-prescription supplements (including but not limited to vitamins, skin and coat supplements, etc.); 4.4 Crates, bedding, food bowls, leashes, collars, and other accessories; 4.5 Toys and treats; 4.6 Grooming tools (including shampoos, conditioners, brushes and combs), or costs and expenses associated with the services of a professional groomer; 4.7 Transportation, including but not limited to transportation of Dog(s) to veterinary appointments, prospective adopter interviews or to NTSRI; 4.8 Veterinary costs and expenses not expressly described in Sections 4.1 and 4.2 above, including veterinary costs and expenses incurred by Caregiver at a veterinarian other than NTSRI’s veterinarian described in Section 3 above, unless prior permission has been granted by NTSRI to use a veterinarian other than that described in Section 3 above; 4.9 Boarding, pet daycare or pet-sitting fees of any kind; 4.10 Carpet or upholstery cleaning, or other household cleaning, repairs or maintenance. IT IS EXPRESSLY AGREED AND UNDERSTOOD THAT CAREGIVER IS ACTING UNDER THIS AGREEMENT AS AN UNPAID VOLUNTEER, AND CAREGIVER SHALL RECEIVE NO WAGES, SALARY OR OTHER REMUNERATION IN CONNECTION WITH CAREGIVER'S ACTIVITIES HEREUNDER. 5. In the event that Dog(s) are lost, stolen, become seriously ill or die, Caregiver shall contact NTSRI immediately. In the case of lost or stolen Dog(s), Caregiver shall assist NTSRI with all reasonable attempts to locate Dog(s). Caregiver shall not be liable to NTSRI for any such loss, theft, illness or death, except, in the sole determination of NTSRI, if such is the result of the negligence or misconduct of Caregiver. 6. Caregiver shall notify NTSRI immediately if it is necessary for Caregiver to be away from home for any period exceeding twenty-four (24) hours. NTSRI shall arrange for alternative accommodations for Dog(s) for the period of the Caregiver’s absence. Under no circumstances shall Dog(s) be boarded or pet-sitting arrangements be made directly by Caregiver without the express prior permission of NTSRI. In the event that such arrangements are pre-approved by NTSRI, Caregiver shall provide NTSRI with full details, including name, address and telephone number of the boarding facility or pet-sitting service, as well as the address and telephone number at which Caregiver may be contacted during Caregiver’s absence. 7. It is expressly understood and agreed that NTSRI may visit the premises of Caregiver where Dog(s) are housed at any reasonable time, with prior notice to Caregiver, in order to ascertain that the premises is a safe and comfortable environment for Dog(s) and that Dog(s) are being cared for in accordance with the terms and conditions of this Agreement. 8. At reasonable times and with prior notice by NTSRI to Caregiver, Caregiver agrees to allow prospective adopters to visit Dog(s), either in the Caregiver’s home or at a location designated by NTSRI (Caregiver shall transport Dog(s) to the premises designated by NTSRI, if so requested, in order to effect the prospective adopter interview). Caregiver further agrees to answer any questions the prospective adopter(s) may have regarding the behavior and personality traits of the Dog(s), in order that the prospective adopter(s) may determine the suitability of Dog(s) for permanent adoption. 9. Caregiver shall notify NTSRI immediately in the event that Caregiver is no longer able or willing to provide foster care to Dog(s). Caregiver shall continue to care for Dog(s) until such time as NTSRI is able to make arrangements for alternate accommodations for the Dog(s), and NTSRI shall make every effort to arrange alternate accommodations as quickly as possible. Caregiver shall provide transportation of Dog(s) to the location designated by NTSRI, and all prescription medication, including heartworm preventative, and veterinary records shall accompany Dog(s) upon the relinquishment of Dog(s) to NTSRI or to the individual(s) in charge of the alternate accommodation chosen by NTSRI. In the event that a permanent adoptive home is approved by NTSRI for Dog(s), Caregiver agrees to relinquish Dog(s) upon notice by NTSRI to do so, at the date, time and location specified by NTSRI. All prescription medication, including heartworm preventative, and veterinary records shall accompany Dog(s) upon the relinquishment of Dog(s) to NTSRI or the permanent adopter(s). 10. Caregiver shall have the first option to request permanent adoption of Dog(s) in Caregiver’s care. In the event that Caregiver chooses to exercise his or her option to adopt Dog(s), Caregiver shall be required to complete and execute NTSRI’s standard Adoption Agreement, and the regular adoption fee ($250) shall be paid to NTSRI. Caregiver’s option to adopt Dog(s) must be submitted to NTSRI before an agreement is entered into between NTSRI and any other prospective adopter of Dog(s). 11. Limitation of Liability. NTSRI, ITS DIRECTORS, OFFICERS, AGENTS, REPRESENTATIVES, SUCCESSORS AND ASSIGNS, SHALL NOT BE LIABLE TO CAREGIVER OR CAREGIVER’S FAMILY MEMBERS, HEIRS, SUCCESSORS, ASSIGNS, INVITEES TO THE CAREGIVER’S PREMISES, OR ANY THIRD PARTIES FOR ANY DEATH, BODILY INJURY, DAMAGE, CLAIM OR LOSS WHATSOEVER, ARISING EITHER DIRECTLY OR INDIRECTLY OUT OF THE SUBJECT MATTER OF THIS AGREEMENT. 12. It is expressly agreed and understood that NTSRI’s remedy in the event of Caregiver’s breach of any of the terms and conditions of this Agreement is relinquishment of Dog(s) to NTSRI and/or liquidated damages in the amount of Five Hundred Dollars ($500). NTSRI reserves the right to seek injunctive relief in the event that Dog(s) are not relinquished within a reasonable period of time after notice of breach has been given to Caregiver. 13. This Agreement may be terminated at any time, for any reason, by either Caregiver or NTSRI. Upon termination, Dog(s) shall be immediately returned to NTSRI. 14. This Agreement shall be governed by the laws of the State of Texas as to all matters, and NTSRI and Caregiver agree that the proper venue for adjudication of any disputes shall be the courts of law located in Dallas, Dallas County, Texas. Attorney’s fees and court costs shall be paid by the party against whom judgment is rendered. 15. This Agreement is the entire agreement between NTSRI and Caregiver and may not be modified in any manner whatsoever except in a writing signed by both NTSRI and Caregiver. 16. Caregiver warrants that all persons over the age of 18 years living in the premises where Dog(s) will be housed intend to be legally bound by this Agreement. Caregiver further warrants that no person in Caregiver’s household where Dog(s) reside has ever been convicted of any offense involving animal abuse or cruelty to animals.
I agree
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