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YWAC Pet Pantry Application
Apply for free pet food to help you keep your pet!
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* Indicates required question
Name
*
Your answer
Email
Your answer
Address
*
Your answer
Phone Number
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
I understand that proof of income (pay stub, benefits letter, W2, etc.) is required to receive assistance from the Pet Food Pantry. I agree to bring proof of income the first time I come to pick up pet food.
*
Yes
No
Do you receive any of the following assistance? (check all that apply)
*
Food stamps
SSI
SSA
WIC
Medicaid/TennCare
Unemployment
Section 8 housing (HUD, KCDC)
None of the above
Other:
Required
What is your annual household income?
*
Your answer
Pet #1 Information
*
Choose
Dog under 10lbs
Dog 11-25lbs
Dog 26-50lbs
Dog 51-75lbs
Dog over 75lbs
Cat
Pet #1 Name, age and breed
*
Your answer
Is Pet#1 spayed or neutered?
Choose
Yes: spayed female
No: intact female
Yes: neutered male
No: intact male
Pet #2 Information
Choose
Dog under 10lbs
Dog 11-25lbs
Dog 26-50lbs
Dog 51-75lbs
Dog over 75lbs
Cat
Pet #2 Name, age and breed
Your answer
Is Pet#2 spayed or neutered?
Choose
Yes: spayed female
No: intact female
Yes: neutered male
No: intact male
Pet #3 Information
Choose
Dog under 10lbs
Dog 11-25lbs
Dog 26-50lbs
Dog 51-75lbs
Dog over 75lbs
Cat
Pet #3 Name, age and breed
Your answer
Is Pet#3 spayed or neutered?
Choose
Yes: spayed female
No: intact female
Yes: neutered male
No: intact male
If you have more than 3 pets please list them here with the same information as requested above.
Your answer
Name of veterinarian
Your answer
How many adults are in your household?
*
Your answer
How many children are in your household?
Your answer
I understand that it is a requirement of the Pet Pantry program that my pets are spayed/neutered. If they are not, Young-Williams will provide information on low cost spay/neuter surgery and I will have 30 days to have my pet(s) spayed/neutered or will be discontinued from the program.
*
Yes
No
I understand that I may not add any more pets to my household while receiving assistance from the Pet Pantry program
*
Yes
No
I understand that Young-Williams Animal Center's Pet Pantry program is intended as a supplemental source of pet food and is not the sole source of food for my pets
*
Yes
No
In the event I cannot pick up pet food I authorize the following person/people to pick up for me
Your answer
I release Young-Williams Animal Center from any claims, liability or damage relating to food I receive through the program, and I waive my right to raise any claims against YWAC
*
Yes
No
Staff use only: Record complete?
Yes
No
Clear selection
Staff use only: File notes/next steps
Your answer
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