2019 Food Bank Application
1) Please note that Lost Our Home Pet Rescue is located in Tempe, Arizona, and only services the greater Phoenix area. We are unable to assist anyone outside of this area. Please contact your local Humane Society for additional resources.

2) You must fill out an application each time you request food for your pets.

3) ALL animals in the home receiving assistance MUST be spayed/neutered. Lost Our Home can assist with spay/neuter vouchers for your pet(s), however until we receive proof of alteration we cannot assist you past the first time. Staff will expand upon this if necessary.

4) You cannot add any additional animals while using the program.

5) All program participants must show proof of identification at time of food pick-up or delivery.

6) All program participants must show proof of their need for assistance (proof of government assistance, unemployment, medical bill, etc.).

7) Although we offer food bank delivery, we cannot guarantee delivery, so it is best to try to find a means of transportation to pick up your food from Lost Our Home. If you have no way of picking up the food, we can add you to a volunteer based delivery list, however we cannot guarantee when/if a delivery will occur.
Your First Name *
Your answer
Your Last Name *
Your answer
Street Address *
Your answer
Unit or Apartment Number
Your answer
City, State, Zip Code *
Your answer
Closest Major Cross Streets *
Your answer
Best Contact Phone Number *
Your answer
Alternative Phone Number
Your answer
Email Address *
Your answer
Have you ever used the Lost Our Home Food Bank Program? *
Do you require pet food delivery? NOTE: We rely 100% on volunteers for pet food delivery. Due to this we cannot always guarantee delivery. *
How many people reside in your home?
Your answer
How many pets are in your home? *
Please Describe each of your Pets: *
Name, Breed, Color, Sex, and Age
Your answer
Are all of your pets altered? If no, please explain why your pets are not altered in the "other" field. *
Please explain why you are currently unable to provide food for your pet(s): *
Your answer
What steps are being taken to remedy your situation? *
Your answer
When will you be able to afford food for your pet(s) again? *
Your answer
What services are you currently receiving (if any)? You will be required to show proof of this at the time of pick up. *
Required
Are you a military vet? *
How many people in your household are age 17 or younger? *
Your answer
Does your annual income fall under the Annual Income Poverty Guideline? NOTE: This information is for internal use only and will not be used to determine the intake of your animal(s). *
Required
What items are you requesting for your pet(s)? *
Required
Is there any additional information you would like us to know?
Your answer
I certify that I am at least 18 years of age and legally capable to sign documents/contracts. *
Type Your Name to Sign
Your answer
I understand that Lost Our Home Pet Foundation's intent is to initially supply food and supplies to families to last for one month. At the end of that month, if you still need assistance, please let us know. The program is intended to assist short term. If you are still experiencing financial difficulty you will need to reapply, and Lost Our Home Pet Foundation will determine whether or not additional assistance will be provided. *
Type Your Name to Sign
Your answer
I understand that the Food Bank Program is funded 100% by donations so funds are limited. Lost Our Home Pet Foundation will select the applicants to receive food, litter, and other supplies based on information provided in this application. False representation of information on this application which results in an approval may leave other families that are more in need being rejected because of lack of funds. *
Type Your Name to Sign
Your answer
I certify the information provided in this application is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this application may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this application. *
Type Your Name to Sign
Your answer
I agree upon acceptance into the Food Bank Program to have all of my un-altered pets spayed/neutered and that Lost Our Home Pet Foundation may provide vouchers for spay/neuter. *
Type Your Name to Sign
Your answer
WAIVER AND RELEASE OF LIABILITY *
Type Your Name to Sign
Your answer
STAFF ONLY: Voucher Used? If yes, Enter Voucher Number:
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Lost Our Home Pet Foundation. Report Abuse - Terms of Service