Name
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Cell
(###)
###
####
Email
Best time to reach you?
Please Select
AM
PM
What type of housing do you live in?
Please Select
Townhouse
Apt/Condo
Single Family Home
Do you own or rent?
Please Select
Own
Rent
If you rent, does your landlord permit dogs?
Please Select
Yes
No
Not Sure
If you rent, is there a weight/size limit on allowable dogs?
Please Select
Yes
No
Not Sure
If yes, what is the weight/size limit?
If you rent, please provide your landlord's name and contact information for verification of requirements:
Work Phone
(###)
###
####
Home Phone
(###)
###
####
Landlord's Email
Do you have stairs in your home?
Please Select
Yes
No
If yes, how many stairs?
Do you have a fenced in yard?
Please Select
Yes
No
If yes, please describe your fence (height, type etc):
f no, do you agree to keep the basset on a leash when outdoors?
Please Select
Yes
No
Are you willing to have a volunteer from BHROM visit your home prior to fostering?
Please Select
How many adults in your household?
Please Select
1
2
3
4
5
6
7
8
9
How many children in your household?
Please Select
0
1
2
3
4
5
6
7
8
9
If there are children in the household, what are their ages?
Are there other children who visit frequently (i.e. grandkids, babysitting)?
Please Select
Yes
No
N/A
If yes, what are the visiting children's ages?
Describe the temperament of the dog(s) you currently own.
Please Select
Dominant
Submissive
Combination of both
N/A
Describe the activity level of the dog(s) you currently own.
Please Select
Docile
Active
Combination of both
N/A
Do you have a veterinarian?
Please Select
Yes
No
If yes, please provide your veterinarian's name and phone number.
First Name
Last Name
Vet's office name
Vet's address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
What pet name and last name are your current vet records under?
Why do you want to foster a Basset?
How do other family members feel about fostering a Basset?
Which family member will be the basset's primary caregiver?
How many hours per day will the basset be left alone?
Please Select
0
1
2
3
4
5
6
7
8
9
10
11
12
Where will the basset be kept during the day?
Where will the basset be kept during the night?
Are you willing to take your foster to a veterinarian on BHROM's approved list?
Please Select
Yes
No
What is the brand name of the dog food you will be feeding your foster?
Have you ever owned a Basset?
Please Select
Yes
No
Have you ever adopted a dog from a rescue organization or shelter?
Please Select
Yes
No
Have you ever fostered for a rescue organization before?
Please Select
Yes
No
If yes, please explain:
Have you ever had to give up a dog?
Please Select
Yes
No
If yes, please explain:
Are you willing to foster a special needs or senior Basset?
Please Select
Yes
No
Are you willing to foster a Basset recovering from surgery and/or on medication?
Please Select
Yes
No
Are you willing to foster a Basset being treated for heartworms?
Please Select
Yes
No
Are you willing to foster more than one Basset at a time?
Please Select
Yes
No
Have you ever taken a dog to obedience training?
Please Select
Yes
No
Are you willing to house train your foster, if necessary?
Please Select
Yes
No
Are you willing to crate train your foster?
Please select
Yes
No
Do you have an available crate for your foster?
Please Select
Yes
NO
If you have crates - how many do you have?
Please Select
1
2
3
4
5
6
7
8
9
What size are your crates?
Are you available by e-mail on a daily basis?
Please Select
Yes
No
Do you have an answering machine or voice mail that you check every day?
Please Select
Yes
No
Do you own a working digital camera or a smart phone to take photos?
Please Select
Yes
No
First Pet – Name
First Pet - Dog (Breed), cat, bird, other
First Pet - AGE (yr/Mos)
First Pet - Time owned
First Pet – Sex
Please Select
M
F
First Pet - Spay/ Neuter
Please Select
Yes
No
First Pet - Date of last inoculations for Rabies
MM
DD
YYYY
First Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
First Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
First Pet - Date of last heartworm test
MM
DD
YYYY
Second Pet – Name
Second Pet - Dog (Breed), cat, bird, other
Second Pet - AGE (yr/Mos)
Second Pet - Time owned
Second Pet – Sex
Please Select
M
F
Second Pet - Spay/ Neuter
Please Select
Yes
No
Second Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Second Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Second Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Second Pet - Date of last heartworm test
MM
DD
YYYY
Third Pet – Name
Third Pet - Dog (Breed), cat, bird, other
Third Pet - AGE (yr/Mos)
Third Pet - Time owned
Third Pet – Sex
Please Select
M
F
Third Pet - Spay/ Neuter
Please Select
Yes
No
Third Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Third Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Third Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Third Pet - Date of last heartworm test
MM
DD
YYYY
Fourth Pet – Name
Fourth Pet - Dog (Breed), cat, bird, other
Fourth Pet - AGE (yr/Mos)
Fourth Pet - Time owned
Fourth Pet – Sex
Please Select
M
F
Fourth Pet - Spay/ Neuter
Please Select
Yes
No
Fourth Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Fourth Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Fourth Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Fourth Pet - Date of last heartworm test
MM
DD
YYYY
Fifth Pet – Name
Fifth Pet - Dog (Breed), cat, bird, other
Fifth Pet - AGE (yr/Mos)
Fifth Pet - Time owned
Fifth Pet – Sex
Please Select
M
F
Fifth Pet - Spay/ Neuter
Please Select
Yes
No
Fifth Pet - Date of last inoculations for Rabies
MM
DD
YYYY
Fifth Pet - Date of last inoculations for DHLPP
MM
DD
YYYY
Fifth Pet - Date of last inoculations for Bordatella
MM
DD
YYYY
Fifth Pet - Date of last heartworm test
MM
DD
YYYY
