Pet Food Assistance

Name *

First

Last

Phone Number *

Address *

City *

State *

Zip Code *

Email *

How many animals are you needing assistance with? *

Animal type *

Please list all animals names *

Breed

Weight *

Age *

Spayed/Neutered *

Special Needs:

~Please specify which animal~

Name of Current or Past Veterinarian or Clinic *

Understand that all pet food and supplies are donated and may not be the current brand you use to feed your pet, which may upset your pet’s stomach. I agree not to hold the Humane Society of the Upper Valley, its volunteers, and benefactors legally liable in the unfortunate event your pet(s) become ill or the food upsets a pets(s) stomach Recipients agree not to resell, redistribute or attempt to return to a store, any food or care items received from HSUV. The Humane Society of the Upper Valley will make every effort to consider special requests for certain formulas or flavors of dog and cat food (i.e., Senior, indoor, etc.), but are only able to give what is available at the time. *

I Understand

E Signature *

First

Last

Date