Hearts Alive Village Pet Food Assistance Application

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Form description

Email *

Terms of this program:

1. The amount of food supplied will be at the discretion of Hearts Alive Village.
2. The food for this program is purchased and donated from various sources. Hearts Alive Village cannot guarantee the freshness, quality or safe consumption.
3. Although we will try our best to meet dietary sensitivities, we cannot guarantee the type of food you may receive.
4. If your animals are not spayed/neutered and you are willing to seek/accept assistance in getting this done, please contact info@heartsalivevillage.org.
5. Food is limited and the purpose of this TEMPORARY assistance with food is to help keep my pets at home and out of the shelter.

6. Food is supplied every 2 months. You can submit a food bank application 2 months after pickup.
7. Hearts Alive Village reserves the right to deny or terminate assistance at their discretion.

Type your full name. By typing my name below, I acknowledge, understand and consent to the above terms. *

Full Legal Name *

How many dogs do you have? *

How many cats do you have? *

Phone Number (ex. ###-###-####) *

Please provide the best number to reach you for verification and/or confirmation of curbside pickup.

Home Address *

ZIP *

Please check any of the following that apply: *

Head of Household

Single Parent

Homeless

Other:

Required

Please check any of the following that apply: *

SSI

SSD

SNAP

Medicaid

Medicare

Veteran

Disabled

Senior (60+)

None of the above

Required

Are your animals spayed or neutered? *

Yes

No, they are not fixed

Currently pregnant

Do any of your animals have dietary considerations? *

Allergy/Sensitivity - Grain Free

Allergy/Sensitivity - Chicken Free

Other:

Required

Are any of your animals currently on prescriptions? If yes, please list *

Other:

Required

Have you ever received pet food assistance before? *

Yes

Please confirm your first and last name below. *

Upon approval, you will be contacted via phone and/or email with further instruction. If you have any questions please send an email to petfoodbank@heartsalivevillage.org

Send me a copy of my responses.

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