FEED the NEED Pet Pantry Application

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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

Country

*State/Province

Date of Birth

* Month

* Day

* Year

Applicant Information

Help us to understand about you and your situation.

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Have you or anyone in your household, ever been charged with any form of animal abuse, cruelty or neglect?

YesNo

If you answered yes to the above question, please provide information

PROGRAM PARTICIPANT GUIDELINES & AGREEMENTS

The GaDaH - FEED the NEED Pet Pantry provides short-term assistance to those in need. In order to allow the program to help as many pets as possible, GaDaH is currently unable to provide food to any one family for more than two years. If approved, pet owners will be eligible to receive free pet food for six months. At the end of that period, they will be asked to complete a renewal application if they wish to continue their enrollment.

It is not our mission to support persons in acquiring "therapy" pets; we do not provide food to feed strays, foster care or outdoor community TNR programs.

PROGRAM PARTICIPANT GUIDELINES & AGREEMENTS

FEED the NEED participants will be unable to adopt or take in more animals while participating in this program.

All pets in the household are required to be spayed/neutered, up-to-date on their rabies vaccines in compliance with state law, and if required, licened with the town office. PROOF is REQUIRED.

A 1-month courtesy period will be granted for families to get the rabies vaccine and a 3-month courtesy period will be granted in order for families to spay/neuter their pets. If no proof of surgery has been provided after 3-months, you will be removed from the FEED the NEED program. There are many low cost options available throughout the state of Maine and you are encouraged to do your own research. One resource is the SpayMaine.Org Website

GaDaH will at times, offer low cost Microchip clinics for program members, who will be required to attend if their pets are not already microchipped. The cost will be no more than $10 and will not involve any other registration fees.

GaDaH is dependent on donations to the FEED the NEED Program. At times there may be limits on the amount of food available to participants. Kibbles are a mixture of donated foods, so that pets are less likely to react to changes in diet from month to month.

GaDaH reserves the right to suspend the FEED the NEED program at any time.

A detailed explanation of how and when to obtain food will be provided once you have been approved into our program.

All questions below must be completed to register in the GaDaH - FEED the NEED Pet Pantry Program.

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I understand that the goal of the GaDaH - FEED the NEED Pet Pantry program is to provide supplemental food to animals whose owners are in financial need, and is not intended to be the sole source of food for my pets.

Type Full Name to state agreement.

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I understand that in order to receive food I must come to the appointed pick up location on days and times provided. If I show up outside of the designated dates and times listed, I will not receive assistance.

Type Full Name to state agreement.

*

I understand that GaDaH accepts all kinds of pet donations. By accepting pet food, cat litter, pet items, or services form the FEED the NEED Pet Pantry, I, and all household members, including their friends and family, agree not to hold GaDaH, its staff, volunteers, agents and or assignees legally liable in the unfortunate event that the recipient’s pet(s) become ill or the food upsets the pets stomach.

Type Full Name to state agreement.

*

I agree that I will not misuse this program. If I am seen abusing the GaDaH - FEED the NEED Pet Pantry, I will be immediately removed. Abuse of the GaDaH - FEED the NEED Pet Pantry is defined by but not limited to, sharing account cards with unauthorized users, accepting food or items that the owner is able to afford, giving food/items to others, reselling food/items, using multiple accounts, and/or compromising the availability of goods for other clients.

Type Full Name to state agreement.

*

I understand that Free dog and cat food will only be provided within limit of donations received. I understand that the pet food and supplies received through the GaDaH - FEED the NEED Pet Pantry program has been donated by manufacturers and individuals and is not for sale to the pubic. Therefore, I agree to use these products for my personal pets only and will not re-sell these products to any person(s) or business(es).

Type Full Name to state agreement.

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How did you hear about our GaDaH - FEED the NEED Pet Pantry? Please be specific as it will help us to continue or change our awareness campaign, to be able to reach as many people in need as possible!

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I accepts that GaDaH reserves the right to revise, alter, or otherwise change any/or all components of the FEED the NEED Pet Pantry Rules & Guidelines
with or without notice to participants.

Type Full Name to state agreement.

*

I am aware of the following DISQUALIFICATIONS:
• If I add additional pets to my household, I will be immediately disqualified, and will no longer be eligible to receive handouts.
• If I fail to produce written verification of spay/neuter and of vaccinations, I will be removed from the program.
• If I or my designated stand-in fail to show up for two consecutive handouts without contacting the Pet Pantry, I will be removed from the program.

Type Full Name to state agreement.

*

I understand that I will be terminated from the GaDaH - FEED the NEED Pet Pantry for being rude or disrespectful to any staff member or volunteer of the FEED the NEED Pet Pantry.

Type Full Name to state agreement.

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I agree that I will inform GaDaH of any change in my financial situation; Any change in my contact information, such as address, phone number or email; The death of my pet.

Type Full Name to state agreement.

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I understand and agree that GaDaH makes no warranties as to the pet food and supplies and does not assume any liability and/or guarantee for these pet food supplies in any way.

Type Full Name to state agreement.

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accept that by completing and signing this application I agree to indemnify GaDaH and its affiliates and hold them harmless from and against any direct, indirect, special, incidental, punitive or consequential damages, including but not limited to the injury to and loss of your pet, which may arise from my decision to accept and use the pet food.

Type Full Name to state agreement.

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*All information provided is used only to determine your need for pet food and supplies. All information must be completed to get assistance. Incomplete or illegible applications will not be accepted.

YesNo

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Are you receiving help with pet food from any other organizations or agencies? If yes, please state which!

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*

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Photo ID of main applicant

Photo ID of secondary pick up person

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Income verification is necessary to be approved as a GaDaH FEED the NEED Pet Pantry Monthly Assistance Program client. Please indicate which form you are attaching and upload by following the link below.

Food StampsHousing AssistanceSSI - Supplemental Security IncomeDisabilitySeverance StatementUnemployment StatementPension Distribution StatementMedicareMedicaidCHIP - Children's Health Insurance ProgramCHIP - Children's Health Insurance ProgramEITC - Earned Income Tax CreditTANF - Temporary Assistance for Needy FamiliesWIC – Supplements Women, Infants, ChildrenForeclosure statement of Low IncomeSubmit explanation of current income along with supporting documents such as copy of prior year tax return, W2s, etc..Other

Income Verification Upload

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Number of adults, 18+ living in the household

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Number of children 17 years and younger living in the household

*

Are any members of the household:

DisabledUnemployedVeteranFormer Law EnforcementSenior - 65+RetiredNone of the Above

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Please provide which members of the household are checked above.

Ie. - Adult Male - Former Law Enforcement; Adult Female - Senior. In none, please put N/A

*

We evaluate each case individually. Your story matters. Why do you need our help? Please describe your situation.

Pet Information

Please provide information on ALL pets you wish to enroll into the FEED the NEED Pet Pantry Program.

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Pet #1
Name
Species and Breed
Male or Female
Estimated age or date of birth
Estimated weight

*

Pet # 1. More Information

Spayed or NeuteredCurrent Rabies VaccineCurrent on Core VaccinesMicrochippedMonthly Flea/Tick prevention

*

Pet # 1.
What food do you currently feed?
How often do you feed?
How much per DAY do you feed?

Pet #3. More Information

Spayed or NeuteredCurrent on RabiesCurrent on Core VaccinesMicrochippedMonthly Flea/Tick Preventatives

Pet # 3.
What food do you currently feed?
How often do you feed?
How much per DAY do you feed?

*

If you have more pets - please provide all of the above information for each other pet

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Have any of your pets been prescribed a Special Diet? Please list pets name, details of prescribed food.

*

Please list where all animals live - indoor or outdoor. If outdoor, provide details.

If outdoor please provide detailed information on any type of shelter, how they are secured ect.

*

Please list any other animals that own and are responsible for.

example - livestock - list species and how many

Please provide proof or rabies and or spay/neuter for each pet.

*

Please upload a clear picture of each individual pet you would like included in the program. One picture must just contain one pet, ensure to label the picture with the pets name.

*

Give a Dog a Home is located in Sebec. Are you able to pick up in Sebec, or any location we are able to set up distribution points at? Times and dates will be published in advance.

If you are unable to travel and do not have a "pick-up person" please explain your situation.

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Sometimes at events and distribution, we take pictures to help promote the cause and also to provide to donors and sponsors to show them the impact of their support. Will you allow GaDaH to take new photos or use the photos you provided of you and/or your pet(s) for promotional purposes?

Yes, you may use/take photos of me and my pet(s)Yes, you may use/take photos of my pet(s) onlyNo, you may not use images of me or my pet(s)

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Are you aware that Give a Dog a Home Rescue also has a WELLNESS on WHEELS Low Cost Pet Services that we hold once a month with a licensed veterinary technician?

For more information on our "Wellness on Wheels" Low Cost Pet Wellness Services, please follow the link to our website and on the menu on the left, click on the relevant link. It is important to note, we do not have a veterinarian so are not able to administer Rabies vaccination, or diagnose/treat any illness.

YesNo

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Would you like to be added to our email distribution list to be invited / informed on our latest community services, events and up date on the work the rescue is doing?

If YES please provide an email address you would like to receive updates.

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Is there anything else you would like to add support your application?

*

The information I have provided is true and correct. I also understand that any false information provided will result in permanent termination from this program.

Please state full name

Pet #3.
Name
Species and Breed
Male or Female
Estimated age or date of birth
Estimated weight

Pet # 2.
What food do you currently feed?
How often do you feed?
How much per DAY do you feed?

Pet #2. More Information

Spayed or NeuteredCurrent on RabiesCurrent on Core VaccinesMicrochippedMonthly Flea/Tick Preventatives

Pet #2.
Name
Species and Breed
Male or Female
Estimated age or date of birth
Estimated weight

I have read and agree to the terms and conditions. By checking this box I am confirming that I am 13 years of age or older.

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