Pet Pantry Request Form for New Clients

Submit an Application

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

General Information

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Reason for request?*

Any special dietary needs?*

Pet 1 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 2 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 3 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 4 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 5 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 6 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 7 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Pet 8 Information

Is your pet a dog or a cat?*

Dog

Cat

Is your pet altered?*

Yes

Pet Name*

Pet Breed*

Pet Age*

Pet Weight*

Do you have an additional pet to add?*

Yes

Additional Pet(s)

Please list any additional pet(s).*

For each pet, please list if your pet is a dog or a cat, whether or not they are altered, and their name, breed, age, and weight.

Pick Up Information

Pickup Date*

Please initial below.*

I agree that for my first order I will be present and bring current photo identification with me to verify my identity. After my first pickup, and my identity has been verified, I may designate someone to pickup for me.

Please initial below.*

I recognize that in receiving assistance in the form of donated pet food there exists risk of injury or sickness, including personal injury or harm to me, my pet(s) and others. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify, and hold harmless Friends of the Cuyahoga County Animal Shelter, and its agents from any and all claims, causes of actions of demands, of any nature or cause connected with my receipt of assistance in any form from Friends of the Cuyahoga County Animal Shelter.

Please initial below.*

I understand that 1) Friends of the Cuyahoga County Animal Shelter has a limited amount of food available for animals in need; 2) the amount of food provided will be determined on a case by case basis, depending on availability and need; 3) a representative will establish a date and time for me to receive the allocated food; 4) based on demand, I will only receive a limited amount of food each month, and FCCAS cannot guarantee how much or how often it can provide food to me for the animals in my care.

Please initial below.*

I understand that this is a free and voluntary service and by making my request I am committing to picking up my order at the time selected above. Should I fail to meet my commitment pick up time, follow any rules set forth, speak or act in a way that is unbecoming or threatening, or for any other reason specified, FCCAS may remove me from the program at will.

Applicant Signature*

Application Date*

MM slash DD slash YYYY

How did you hear about us?*