Spouse or significant other's name:

Address:

City:    State:   Zip:

Home Phone number:  
Cell or other number:

Email address:

Are there children in the home? Yes No
If yes, their ages?

Who will be the primary caregiver of the bird?

Do you have other birds now? Yes No
If yes, how many and what species?

Have you had birds in the past? Yes No
 If yes, when and what species?

How many hours daily will the bird be left alone?

What type of dwelling do you live in? (i.e. house, apartment)

Do you, or does anyone else, in your home smoke? Yes No

Do you use Teflon, other non-stick cookware, non-stick irons,
or other items such as curling irons? Yes No

What other pets do you have?

What species of bird are you primarily interested in?

Do you understand there will be, and agree to pay an
Application Fee for any bird you receive? Yes No

Most Application Fees will be minimal. However, some will
be greater due to medical bills.

Are you aware that birds:

• Require a great deal of attention and maintenance? Yes No
• Are very expensive to feed, keep healthy, and
  keep entertained? Yes No
• May have or may develop undesirable habits such as screaming, biting, destruction of any object within reach, dislike of strangers or your mate, messy, wasteful? Yes No
• Can be destructive? Yes No
• Can be loud and cause audio disturbances that neighbors may complain about? Yes No
• Require a minimum of an annual visit to a qualified aviary vet for a general check-up? Yes No
• Must be bathed and clipped regularly? Yes No
  
  Tell us about yourself.
  

Contract:
I understand that this bird is being placed in my care under the "trust" that I will take proper care of it.  I also understand that if the bird becomes ill, I must contact STARescue immediately if there is a chance the bird has a transmissible illness.

I acknowledge by typing my name in the signature space below, that I have read and understood this agreement and that all information provided is correct.

Electronic signature:

Date (mm/dd/yyyy):