Foster Family Application

Name:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Cell Phone:*
Work Phone:*
Email:*
 
Information About Your Household
Persons in household and ages:*
Is everyone in the household supportive of having a dog in the home?*
Home:*
Own
Rent
If rental, do they allow dogs?
Landlord’s name and phone number?
 
Pets and Training
Pets in Household (Please give the names and describe type, breed, spayed or neutered, sex and age of each):*
Are the pets friendly with dogs?
If you have owned dogs in the past that are no longer part of your family, please describe them and what happened to them:
Previous dog training experience is not required; however, it is helpful. Please describe any relevant experience:*
 
Fostering an ADAI Dog
What age of dog would you be interested in fostering*
Puppy
Adult
Either
Do you have a fenced in yard? If not, how will you allow the dog to relieve itself and get exercise?*
Who will have the primary responsibility for care and training of the dog?*
Where will the dog stay during the day and at night?*
How many hours maximum do you anticipate your dog will be without human contact each day because of work, etc.?*
 
Volunteering
Why do you want to be an ADAI volunteer?*
How did you hear about our program?*
Have you ever pled no contest, had adjudication withheld, or been convicted of a felony or misdemeanor?*
Yes
No
If yes, please describe charge and penalty or sentence:

Confidentiality Policy

It is the policy of Assistance Dogs of America, Inc. that trustees, employees and volunteers of Assistance Dogs of America, Inc. may not disclose, divulge or make accessible confidential information belonging to or obtained through their affiliation with Assistance Dogs of America, Inc. to any person, including relatives, friends, and business and professional associates, other than to persons who have a legitimate need for such information and to who Assistance Dogs of America, Inc. has authorized disclosure.  Trustees, employees and volunteers shall use confidential information solely for the purpose of performing services as a trustee or employee or volunteer for Assistance Dogs of America, Inc.  This policy is not intended to prevent disclosure where disclosure is required by law.

Trustees, employees and volunteers must exercise good judgment and care at all times to avoid unauthorized or improper disclosures of confidential information.  Conversations in public places, such as restaurants, elevators, and airplanes should be limited to matters that do not pertain to information of a sensitive or confidential nature.  In addition, trustees, employees and volunteers should be sensitive to the risk of inadvertent disclosure and should, for example, refrain from leaving confidential information on desks or otherwise in plain view and refrain from the use of speaker phones to discuss confidential information if the conversation could be heard by unauthorized persons.

At the end of a trustee’s term or upon the termination of an employee’s or volunteer’s employment, he or she shall return at the request of Assistance Dogs of America, Inc., all documents, papers, and other materials, regardless of medium, which may contain or be derived from confidential information, in his or her possession.

Examples of confidential information include, but not limited to, donor information, personnel records, evaluations, compensation and salary information.  Employees of Assistance Dogs of America, Inc. will make an effort to limit volunteer, guest, donor, graduate and applicant exposure to confidential information.

Media Release Authorization

I  hereby give permission to Assistance Dogs of America Inc. (ADAI)  and/or parties designated by ADAI to photograph me and use these photographs and other information in all forms of media for any and all promotional purpose including advertising, publicity, display, audiovisual, exhibition, commercial or editorial use.

I understand that the term ”Photograph” as used herein encompasses both still photographs, audio and video recordings, and motion picture footage.

I further consent to the reproduction and/or authorization by ADAI to reproduce and use such photographs for use in all domestic and foreign markets.

I hereby release ADAI and any of its associates, affiliates, appointed advertising agencies and designated directors, officers, agents, employees, and customers from any claims.

Waiver of Liability Medical Hold Harmless

In consideration of the acceptance of my decision to become a client/graduate/puppy raiser/foster/volunteer for Assistance Dogs of America, Inc. (ADAI), I, the undersigned, my heirs, executors, administrators and assigns, hereby waive and release any and all claims for damages, death, personal injury, loss of property or property damage that I may have, or that may subsequently accrue to me, or to my heirs, executors, administrators and assigns, as a result of my participation as a client/graduate/puppy raiser/foster/volunteer in any and all activities connected with Assistance Dogs of America, Inc., including but not limited to care, instruction, training and cleaning of the dogs at or about the ADAI Education and Training Facility in Swanton, Ohio.   I, the undersigned, discharge and release in advance the promoters, sponsors, volunteers, shareholders, directors, officers, or employees, or others connected with ADAI and their respective agents, boards, commissions and any other involved person, group or entity, without limitation, from any and all liability arising out of or connected in any way with my participation in the above-mentioned client/graduate/puppy raiser/foster/volunteer activity, even though that liability may arise out of negligence or carelessness on the part of persons or entities mentioned above.  

I acknowledge that my client/graduate/puppy raiser/foster/volunteer actions connected with Assistance Dogs of America, Inc. and the dogs themselves, contains some risk.  My participation is voluntary and done at my own risk.  I voluntarily assume all risk of loss, damage or injury that may be sustained while participating in the above-mentioned event.  I attest that I am physically fit and sufficiently trained in the type of matter.  I understand and agree that medical or other services rendered to me by, or at the instance of, any of the persons or entities mentioned above is not an admission of liability to provide or continue to provide such services, and is not a waiver by any person or entity mentioned about of any right hereunder.  

I further understand that serious actions occasionally occur during the handling, care and custody of pets, including dogs at or connected to ADAI.  Knowing of the risks connected with the training, care or teaching of these animals, I nevertheless hereby agree to assume those risks and release and hold harmless all persons and entities mentioned above who, through negligence or carelessness or otherwise may be liable to me (or my heirs, personal representatives or assigns) for damages.  

By voluntarily participating in Assistance Dogs of America, Inc.(ADAI) activities and events and involving myself, I agree to allow ADAI staff, volunteers or other affiliates:

  • to seek medical treatment and care for me as may deemed necessary if I am unable to make such medical discussions.
  • not to seek medical treatment and care for me

 

 All fields marked with an asterisk (*) are mandatory.
   

Thank you for your interest in our program. Being a foster parent to one of our trainees is a very rewarding experience.  Your application will be reviewed and an ADAI representative will contact you in the near future.