YWAC Pet Pantry Application

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Apply for free pet food to help you keep your pet!

Name *

Address *

Phone Number *

City *

Zip Code *

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

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? *

Pet #1 Information *

Pet #1 Name, age and breed *

Is Pet#1 spayed or neutered?

Pet #2 Information

Pet #2 Name, age and breed

Is Pet#2 spayed or neutered?

Pet #3 Information

Pet #3 Name, age and breed

Is Pet#3 spayed or neutered?

If you have more than 3 pets please list them here with the same information as requested above.

Name of veterinarian

How many adults are in your household? *

How many children are in your household?

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

I understand that I may not add any more pets to my household while receiving assistance from the Pet Pantry program *

Yes

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

In the event I cannot pick up pet food I authorize the following person/people to pick up for me

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

Staff use only: Record complete?

Yes

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Staff use only: File notes/next steps

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