King S Harvest Ministries

King’s Harvest Ministries Reviewed: Pet Assistance Program Date:______5837 Wisconsin Ave INITIAL:______Davenport, Iowa 52806

Temporary Care Application ______

I am interested in caring for (please X the following):

Kittens(s) ____ Adult cat ____ Pregnant/nursing Cat ____ Under socialized cat/dog____

Puppy(s)____ Adult Dog ____ Pregnant/nursing Dog___ Senior/special needs cat/dog_____

Orphaned bottled fed Kittens______Orphaned bottle fed puppies______

Dog recovering from surgery/illness______Cat recovering from surgery/illness______

Would you consider a special needs animal, such as one that requires daily medication: Y N

How long will you provide care: ____ Short term (emergency, overnight, no longer than 1 week) ____ Long term (until permanent home is found) ____ Other (You list) ______

Name (Print): ______Email: ______Street Address: ______Apt#______City/Zip: ______Daytime Phone: ______Evening Phone: ______Cell Phone: ______Company Name:______Occupation: ______Full time or Part Time: FT PT Drivers License #: ______State: ____ County:______

Are you over 21 years of age: Y N

Have you ever been convicted of animal cruelty, neglect or abandonment? Y N

Do you: Rent/Lease [ ] Own [ ] Live with parents [ ] Do you live in: House w/yard House w/acreage Apartment Townhouse/Condo Mobile Home

If you rent, is your lease: Yearly [ ] Monthly [ ] Name of complex and/or association: ______Name and phone # of landlord or owner: ______PET POLICY: ______How long have you been at this address? ______

Is your yard fully fenced: Y N How high?______Cedar____ Chain link____ Other____ Any gaps or missing areas: Y N Are gates secured: Y N Do you have a kennel or dog run: Y N If no to fenced yard or kennel, how will exercise/toilet be handled: ______

1 Would you agree to a King’s Harvest Ministries team member to check your property prior to taking animals into your home? Y N

How many adults reside at this address? ______

Are there children in your home? Y N If yes, how many and what are their ages? ______

Do you have any grandchildren who visit often Y N

Would there be anyone at home during the day? Y N If yes, who? ______

Anyone in your home with a disability, special needs, or elderly: Y N Describe: ______

Is there anyone in your home with animal related allergies? Y N Explain: ______

Do you have any dogs and/or cats at home now? Y N Name______Age _____ Breed ______Sex____ Spayed/neutered: Yes [ ] No [ ] Name______Age _____ Breed ______Sex____ Spayed/neutered: Yes [ ] No [ ] Name______Age _____ Breed ______Sex____ Spayed/neutered: Yes [ ] No [ ] Name______Age _____ Breed ______Sex____ Spayed/neutered: Yes [ ] No [ ] Name______Age _____ Breed ______Sex____ Spayed/neutered: Yes [ ] No [ ]

Approximate date and reason of last vet visit: ______Are they current on vaccinations? Y N If no, why not:______

Have you had other pets in the past 5 years?Yes [ ] No [ ]

Where are they now?______

The pets you currently own where do they live indoors/outdoors or both:______

Have you ever lost an animal to illness or injury? If so please explain______

Have you recently lost a pet to parvo or distemper within the past 6 months? Y N

Name/Phone of your vet: ______

Do you breed any animals or show?______

Are you a part of any animal organization? Yes No

If Yes, Which one: ______

Do you care for animals in your home for them? Y N

Why would you like to care for one of our rescues? ______How many hours per day would our animal(s) be WITHOUT an adult caregiver?:______

Are you willing to use a crate if the dog/puppy(s) or kitten(s) is used to being crated: Y N

How will you keep the animal(s) you are caring for us separate from your resident animal(s) please describe? ______

Are you willing and able to take the animal to pre approved vet appointments, adoption events, pre approved grooming appointments and allow potential adopters to visit the animal? Y N Explain why not?______All pre approved vet and grooming expenses are paid for by King’s Harvest Ministries. Those not approved will be your responsibility.

What ages and conditions (medical care, behavioral problem) would you NOT be willing to help care for? ______

Are you willing and able to medicate an animal if necessary, even if it is only a monthly heartworm tablet? Y N

Briefly describe the experience and skills that you feel will make you a good temporary parent:______

Please list and explain all other relevant experiences you’ve had caring for animals, talents, professions, activities, or any other information you think it would be helpful for us to know about:______

Please provide 2 references: Do not list your veterinarian here, and please list no more than one family member.

Name:______Relationship:______Phone #:______Yrs Known___

I, ______, agree that all of the information which I have given above is correct as written and I authorize the King’s Harvest Ministries(KHM) Pet Assistance Program to verify any information. By signing below, I acknowledge that I completely read this questionnaire, comprehend it fully, know that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application or the agreement form can result in the forfeiture of any KHM animal cared for by me. I certify that the above information is correct, and I understand that the information will be verified.

Please read the following carefully: KHM will determine the criteria for temporarily housing an animal, decide which animals will be cared for, and appoint temporary care givers from a pre-approved list. Approved homes may always refuse any specific request due to timing or other reasons. The KHM team will inform you of any medical treatments to be given, the expected length-care period, the objective of the care (restoring to health, rearing to adoptable age, socializing, etc.), and any other expectations we have. You will be expected to keep the animal secure, return it to KHM when requested to do so, and not promise the animal to anyone, or imply that you have the authority to approve a potential adoption. KHM retains ownership of all animals in your care, and will make all decisions regarding the adoption, vetting and needs of the animals. The KHM team will handle all adoptions. I understand that all animals belong to KHM and I will not re-home any animal without written permission from the directors of KHM. I will not transfer this (these) animal(s) to a third party without KHMs' approval. If I decide to adopt the animal, I will fill out an application and pay the appropriate adoption fee. KHM will make the final decision on the adoption home.

I am responsible for the daily care (feeding, shelter, exercise, toys) for the KHM animal for the period in which he/she remains in the care at my home. I agree that at any time I can no longer care for the KHM animal in my care, I will immediately notify KHM so other arrangements can be made.

By signing this agreement I understand that the animal(s) are in the loving care of KHM. KHM is responsible for PRE APPROVED medical care this animal may require, as a care giver I am responsible for transportation to the veterinarian for treatments and medical care. A lead team member such as the program coordinator, executive director or team leader of KHM must PRE APPROVE and PRE ARRANGE for ALL veterinary care except in the case of severe emergency. All grooming is paid for by KHM for our animals, MUST BE PRE APPROVED and the care giver is responsible for transportation of their animal to the approved groomer. As the temporary home I agree to transport my foster to the veterinarian, adoption events and groomer as needed.

I have read and understand the statements above. I understand that by signing this form I agree to release and covenant to hold harmless The King’s Harvest Ministries Pet Assistance Program and its members from any claims, damages, costs, or actions incurred as a result of the care or actions of the animal. I accept full responsibility for the animal(s) actions at all times, and release the KHM from any liabilities or damages that may be incurred as a result of caring for such animal(s). I agree that the KHM is not liable under the concept of charitable immunity. Further, I understand that although the King’s Harvest Ministries takes reasonable care to screen animals for temporary placement, it makes no guarantees relating to the animals’ health, behavior, or actions. I understand that I receive temporary animals at my own risk and can reject or return any animals for which the KHM has asked me to provide care. I acknowledge that the King’s Harvest Ministries is not responsible for any property damage or personal injury suffered by me, members of my household, or any third parties during a temporary care placement, and I assume all liability to provide adequate controls to prevent such damage or injury. ______Signature Print name

Date ______KHM Volunteer Signature ______

Comments:______Approved: Y N Home Visit Completed: Y N