FOOD ASSISTANCE PROGRAM
Welcome to Companion Pets of Cleveland Food Assistance program.
Your membership allows a monthly pickup of dry and or wet food for your pet(s) for one year. Because we are donation-based, we cannot promise specific food types or name brands.
The application you will fill out has many questions regarding you and your pets. There are no judgments, and the statistical information provided from your answers will be used in the future to secure grant funding, partnership opportunities, spay/neuter program expansion, additional public service opportunities, etc..
We will contact you once the form is received to schedule an appointment to pick up food. This allows us to make sure we have what you need. You will receive a welcome letter with a membership ID # and a resource sheet at your first pick up..
When you need more food please use our Food Assistance Reorder form via the Companion Pets of Cleveland website. If food availability becomes an issue, you will be given a Resource guide that lists many services available in the Northeast Ohio area.
VIP Petcare administers both cat and dog vaccines at their office twice a month: FVRCP, leukemia and Bordetella. They insert Microchips and do Heartworm tests for dogs and FeLv/FIV tests for cats.
TRANSPORTATION: It is your responsibility to have reliable transportation to the pantry. If their are extenuating circumstances, please discuss them with a CPOC representative.
We believe in this program and would like to see it continue!
Bob Stevens
Founder, Executive Director
Carol Rini
Food Assistance Program Chair
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* Required
NAME (Legal Owner)
*
Your answer
STREET # and NAME
*
Your answer
CITY, STATE & ZIP
*
Your answer
EMAIL ADDRESS
*
Your answer
PHONE: HOME or CELL
*
Your answer
CAN WE TEXT THIS NUMBER
*
YES
NO
HOW WOULD YOU LIKE TO HEAR FROM US PRIMARILY?
*
TEXT
eMAIL
PHONE
GOVERNMENT ASSISTANCE (SELECT ALL THAT APPLIES)
*
SECTION 8 or PUBLIC HOUSING
MEDICAID
MEDICARE
VETERAN BENEFITS LETTER
SSI or SSDI (DISABILITY)
UNEMPLOYMENT COMPENSATION
OHIO WORKS FIRST
WIC
OHIO DIRECTIONS CARD (FOOD STAMPS)
SOCIAL SECURITY (RETIREMENT)
GROSS HOUSEHOLD INCOME less than 150% of the Federal Poverty Level
Required
ARE YOU A MILITARY VETERAN?
*
YES
NO
HOW DO YOU IDENTIFY?
*
MALE
FEMALE
NON BINARY
AGE RANGE
*
18-25
26-54
OVER 55
NAME OF PET #1
*
Your answer
SPECIES OF PET #1:
*
CAT
DOG
Required
GENDER of PET #1:
*
Male
Female
Required
APPROX. AGE OF PET #1: Years, Months or Weeks?
*
Your answer
APPROX. WEIGHT OF PET #1:
*
Your answer
IS PET #1 THE SIZE OF:
*
Small: Yorkie, Maltese or a Shih Tzu
Medium: Boxer, Labrador Retriever, PitBull
Large: Great Dane, Rottweiler, Bullmastiff
BREED of Pet #1: Tabby, DLH, DMH, DSH, Calico, etc.?
*
Your answer
COLOR of Pet #1
*
Your answer
IS PET #1:
*
SPAYED
NEUTERED
NO, but might be interested in help with having it done.
Required
CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply:
*
Yes, my pet needs their vaccinations. (Distempter, Bordetella & Leukemia)
Yes, my cat needs a microchip.
Yes, my dog needs a microchip.
Yes, my dog needs Heartworm tested.
Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)
No, my pet does not need these services. I do not need more information.
Required
NAME of PET # 2:
Your answer
SPECIES of PET #2:
CAT
DOG
GENDER of Pet #2:
MALE
FEMALE
APPROX. Age of Pet #2: Years, Months or Weeks?
Your answer
APPROX. WEIGHT of PET #2:
Your answer
IS PET #2 THE SIZE OF:
Small: Yorkie, Maltese or a Shih Tzu
Medium: Boxer, Labrador Retriever, PitBull
Large: Great Dane, Rottweiler, Bullmastiff
Clear selection
BREED of Pet #2: Tabby, DLH, DMH, DSH, Calico, etc.?
Your answer
COLOR of Pet #2
Your answer
IS PET #2:
Spayed
Neutered
NO, but might be interested in help with having it done.
CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply:
Yes, my pet needs their vaccinations. (Distempter, Bordetella & Leukemia)
Yes, my cat needs a microchip.
Yes, my dog needs a microchip.
Yes, my dog needs Heartworm tested.
Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)
No, my pet does not need these services. I do not need more information.
NAME of PET #3
Your answer
SPECIES of PET #3:
CAT
DOG
GENDER of Pet #3:
MALE
FEMALE
APPROX. Age of Pet #3: Years, Months or Weeks?
Your answer
APPROX. WEIGHT of Pet #3:
Your answer
IS PET #3 THE SIZE OF:
Small: Yorkie, Maltese or a Shih Tzu
Medium: Boxer, Labrador Retriever, PitBull
Large: Great Dane, Rottweiler, Bullmastiff
Clear selection
BREED of Pet #3: Tabby, DLH, DMH, DSH, Calico, etc.?
Your answer
COLOR of Pet # 3
Your answer
Is Pet #3:
SPAYED
NEUTERED
NO, but might be interested in help with having it done.
CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply:
Yes, my pet needs their vaccinations. (Distempter, Bordetella & Leukemia)
Yes, my cat needs a microchip.
Yes, my dog needs a microchip.
Yes, my dog needs Heartworm tested.
Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)
No, my pet does not need these services. I do not need more information.
NAME of PET #4
Your answer
SPECIES of PET #4
CAT
DOG
GENDER of PET #4
MALE
FEMALE
APPROX. Age of Pet #4: Years, Months or Weeks?
Your answer
APPROX. WEIGHT of Pet #4:
Your answer
IS PET #4 THE SIZE OF:
Small: Yorkie, Maltese or a Shih Tzu
Medium: Boxer, Labrador Retriever, PitBull
Large: Great Dane, Rottweiler, Bullmastiff
Clear selection
BREED of Pet #4: Tabby, DLH, DMH, DSH, Calico, etc.?
Your answer
COLOR of Pet # 4
Your answer
Is Pet #4:
SPAYED
NEUTERED
NO, but might be interested in help with having it done.
Clear selection
CPOC IN PARTNERSHIIP WITH VIP PETCARE OFFERS VACCINATIONS, MICROCHIPS & MORE FREE OF CHARGE. Select ALL that apply:
Yes, my pet needs their vaccinations. (Distempter, Bordetella & Leukemia)
Yes, my cat needs a microchip.
Yes, my dog needs a microchip.
Yes, my dog needs Heartworm tested.
Yes, my cat needs FELV/FIV tested. (Feline Immunodeficiency Virus, Leukemia Virus)
No, my pet does not need these services. I do not need more information.
ADDITIONAL PET's (Please include name, species, weight, age, spay/neutered, breed) If no use N/A.
*
Your answer
Do any of your pets require a special diet or on a medicated food? If no use N/A:
*
Your answer
WHAT DO YOU NEED? (Select All That Apply)
*
Cat Food
Kitten Food
Does your cat/kitten eat canned food?
Dog Food
Puppy Food
Does you Dog/Puppy eat canned food?
Litter (if available)
Required
HOW DID YOU HEAR ABOUT CPOC?
*
FRIEND
FACEBOOK
HUMAN FOOD PANTRY
MAY DUGAN CENTER OR OTHER SOCIAL SERVICES ORGANIZATION
OTHER
VETERINARIANS NAME & PHONE NUMBER:
Your answer
Any additional information you wish to share? If no use N/A:
*
Your answer
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