FCCAS Pet Pantry Request Form for New Clients -

Full Name(required)

Address(required)

City(required)

State(required)

Zip(required)

Telephone(required)

Email address(required)

How many dogs and/or cats do you have in your home?(required)

Please list the NAME of each dog/cat in the home, along with their BREED, AGE and WEIGHT. (required)

Are your pets altered? Which are, and which are not?(required)

Reason for request?(required)

Any special dietary needs?(required)

Pickup Date (required)

Will someone be picking up for you?(required)

If someone is picking up for you, what is the person's first and last name?

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.(required)

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.(required)

Please initial below: I understand that this is a 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, FCCAS may remove me from the program at will.(required)

Applicant Signature: (required)

Application Date:(required)

**Administrative only: Received by?

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