Application for Dog Food Assistance
Chesapeake Humane Society (CHS) is a non-profit 501(c)(3) organization. CHS's Pet Food Pantry offers assistance to help individuals and families in need to feed their pets with a goal of keeping pets in their homes.
Full Name *
Address (include street, city, state, and zip code) *
Phone Number *
Email Address *
Please explain why you need assistance at this time *
Is this need temporary or long-term? *
Are you able to pick up the pet food from CHS? *
If you answered no above, do you have a friend or family member who can pick up the pet food?
Clear selection
How many dogs do you need pet food for? *
Please list your dog/s information below. Please include your dog/s name, age, and approximate weight. *
Is your dog/s spayed and/or neutered *
Is your dog/s up to date on rabies vaccine? *
How did you acquire your dog/s? *
Required
Waiver: I hereby waive, release, and discharge for myself, my heirs, personal representatives, and assigns any and all rights, liability, causes of action and claims that may now or hereafter accrue to me or which I may now or hereafter assert against the Chesapeake Humane Society, their officers, directors, employees, volunteers, agents, successors, and assigns for any injury, harm or loss suffered by me, my family, or an animal-related to or arising from my acceptance or use of food received from the Chesapeake Humane Society’s Pet Pantry. By signing your name below, you are acknowledging that you understand and agree to all of the provisions above. *
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