Pet Food Pantry Request Form for Existing Clients Submit an Application "*" indicates required fields Have you ordered from the pantry before?* Yes No If you are new to the pantry, please apply here instead. Thank you!General InformationName* First Last Email* Phone*Has your address changed since your last delivery?* Yes No Please update your address below.* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have there been any changes in the number/types of household pets since your last delivery?* Yes No Pet 1Is your pet a dog or a cat?* Dog Cat Is your pet altered?* Yes No Pet Name* Pet Breed* Pet Age* Pet Weight* Do you have an additional pet to add/edit?* Yes No Pet 2Is your pet a dog or a cat?* Dog Cat Is your pet altered?* Yes No Pet Name* Pet Breed* Pet Age* Pet Weight* Do you have an additional pet to add/edit?* Yes No Pet 3Is your pet a dog or a cat?* Dog Cat Is your pet altered?* Yes No Pet Name* Pet Breed* Pet Age* Pet Weight* Do you have an additional pet to add/edit?* Yes No Please list changes for and/or add 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 InformationPickup Date*Please Select OneSunday, 9:00 a.m. to 11:00 a.m.Monday, 10:00 a.m. to 4:00 p.m.Will someone be picking up for you?* Yes No 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. 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 date(s) and time(s) 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; 5) FCCAS reserves the right to request proof of assistance needed for my request. 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. Applicant Signature*Application Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.