Request for Crisis Foster

By completing the form below, you are requesting that CT Humane Society consider your pet(s) for a Crisis Foster placement. CHS may work with partnering boarding facilities to help pets and owners that are candidates for the program. The following information below will help us determine possible arrangements to help your pet(s). Submitting this form does not guarantee your request has been approved or that your pet(s) has placement within our Crisis Foster program. All requests are reviewed and evaluated within the scope of the program’s purpose and capacity, and take into consideration each individual’s needs and circumstances, and the unique needs and history of each pet(s). We realize that some requests may be time sensitive and we will do our very best to respond as quickly as possible, but please allow up to 5 days for our team to respond once submitted. Thank you.

Have you already called us about this pet?*

Yes
No

Please provide your Hotline number here:*

CHS will not respond to inquiries without a valid hotline number.

Which CHS shelter is closest to you?*

Newington, 701 Russell Road
Waterford, 169 Old Colchester Road, Quaker Hill
Westport, 455 Post Road East

PET OWNER CONTACT INFORMATION

Name:*

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone:*

Secondary Phone:

Which phone number can receive text messages? Check all that apply.*

Primary number
Secondary number
Neither

Email:*

Preferred method of contact:*

Phone
Email

What is the best time to contact you?*

Emergency Contact Information

Emergency Contact Name:*

Prefix First Last

Address*

Street Address Address Line 2 City State ZIP Code

Primary Phone:*

Secondary Phone:

Text Messages:*

Yes
No

Email:*

REASON FOR APPLICATION

Why are you seeking temporary foster placement for your pet(s)?*

What is the length of time you anticipate needing emergency foster?

Do you need financial assistance ("SAF") for your pet's care?*

What amount of money are you able to put toward your pet's care currently?*

What is an estimated amount you may be able to save up for your pet's care before the end of your foster need?*

Has your pet ever bitten an animal or person?*

Yes
No

Date of bite:*

Please describe the circumstances of the bite(s) in as much detail as possible:*

YOUR PET'S MEDICAL HISTORY

Pet's Name:*

Species and Breed:*

Age or DOB:*

Is your pet spayed or neutered?*

Your pet is spayed or neutered if a veterinarian did surgery to prevent him/her from having babies.

Yes
No

Has your pet ever received a rabies vaccine?*

Yes
No

What was the vaccination date?*

When is the rabies booster due date?*

What is the rabies tag number?*

Has your pet ever been to a veterinarian?*

Yes
No

When was your pet's last veterinary visit?*

Name and phone number for your pet's veterinary hospital or clinic:*

Is your pet microchipped?*

Yes
No
I don't know

What is the chip number and company?

Does your pet have any pre-existing medical conditions?*

Yes
No

Please describe all medical conditions:*

Is your pet on a special diet?*

Yes
No

Do your feed canned, dry or both?*

What brand of food do you feed your pet?*

How much and how often does your pet eat?*

How does s/he react at the veterinarian?*

Has your pet ever needed to wear a muzzle and/or be medicated for a veterinary examination or vaccinations?*

Yes
No

Please list all medications your pet is currently taking:*

Is your pet on flea and tick preventatives?*

Yes
No

What brand and when was it last applied/given?*

Is your pet taking heartworm preventatives?*

Yes
No

What brand and when was it last given?*

TELL US ABOUT YOUR PET

Do any adults live with your pet?*

Yes
No

List the ages of all adults who live in the household:

Do any children live with your pet?*

Yes
No

List the ages of all children who live in the household:

Do any other animals live with your pet?*

Yes
No

Please list the ages and species of all other animals living in the household:

Is your pet crate trained?

Yes
No

How does your pet react when left alone?*

Where does your pet stay when you are not at home?*

How many hours a day is your pet left alone?*

None
1-5
5-10
More than 10 hours

Has this pet attended a boarding or daycare facility? (Check all that apply.)*

Boarding
Daycare
No

What is the name of the facility?

Does your pet require frequent grooming?*

Yes
No

How often is your pet groomed?

Does your pet have urine or stool accidents in the home?*

Yes
No

How often?

Daily
Weekly
Monthly

Is your pet litter box trained?

Yes
No

What type of litter do you use?

How does your pet react when on a leash?

How does your pet react when people he/she knows visit?*

How does your pet react when meeting strangers?*

Has your pet met kids?*

Yes
No

What are the ages of the children your pet has met?*

How does your pet react with kids he/she knows?

How does your pet react with kids he/she does not know?

Does your pet enjoy car rides?*

Yes
No

Is your pet vocal?*

Yes
No

When is your pet most vocal?

Is your pet frightened of anything (IE: fireworks, etc.)?*

Yes
No

List what he/she is afraid of:*

Describe your pet's personality:*

How energetic is your pet?*

Low
Medium
High

What do you do with your pet for playtime?

Does your pet like to play with toys?

Yes
No

What kind of toys?

Is your pet destructive with his/her toys? (shreds, chews, ingests, etc.)

Is there anything else you would like CHS to know or consider about your pet?*

Please attach several photos of your pet.

Drop files here or

Max. file size: 256 MB, Max. files: 4.

If you have any medical records for your pet(s) such as rabies certificates, please upload them here.

Drop files here or

Max. file size: 256 MB.

By ticking the checkbox below I/We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are for the above mentioned pet(s).*

Yes, the information submitted is accurate, correct and complete.

In addition to CHS' foster contract, if there is opportunity for placement with an outside facility, you may be required to sign an additional contract with that facility. This contract may include language that relinquishes ownership of your pet if you do not pick up your pet within the agreed upon time frame. Please be sure to read through the terms of any external contracts before signing, as CHS is not responsible or involved in those contracts.*

Yes, I acknowledge.

Today's Date:*

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I give CT Humane Society permission to use the following personal/owner information if my pet is selected to be featured in a story:*

As a nonprofit organization, the Connecticut Humane Society and its public medicine clinic rely 100% on donations. We receive many requests for financial support above and beyond the reduced service fees (which are made possible by donor support). The SAF tries to provide additional aid for those who are in the most financial need or who would likely feel they have to rehome their pet if they do not receive assistance.

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About Us

Education and Outreach

Programs and Services

Resources

Adopt

Volunteer

Donate

Events/Service Projects

Request for Crisis Foster

PET OWNER CONTACT INFORMATION

Emergency Contact Information

REASON FOR APPLICATION

YOUR PET'S MEDICAL HISTORY

TELL US ABOUT YOUR PET

Save Lives Today

$25/MONTH

$100

$72

$50

Newington / Offices

Fox Memorial Clinic

Waterford

Westport

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$25_/MONTH