FCCAS Pet Pantry Request Form -

Name(required)

Address(required)

City(required)

State(required)

Zip(required)

Phone(required)

Email address(required)

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

How many people are in your home? Please include the number of both adults and children.(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)

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) food will be disbursed by delivery only, and a representative will establish a date and time to drop off food allocated to me; 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)

Applicant Signature: (required)

Application Date:(required)

**Administrative only: Received by?

**Administrative only: Date of application receipt?

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