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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

ResQ Pantry Questionnaire

This form registers you for participation in the ResQ Pantry program. If approved, you will be contacted with information on how we are able to assist you and your pet(s). In emergencies, please contact us at resqpantry@gmail.com or helpmeowt@totheresq.org.

To The ResQ does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations.

Please indicate how many pets you have in your household.

Example: 2 dogs, 4 cats, 1 rabbit

For which pets in your household are you requesting food assistance? Provide the following information about each pet: name, type (cat/dog/bird), pet's age, approximate weight.

Example: 1) Boots, cat, 2 yrs, 8 lbs 2) Fido, dog, 5 yrs, 35 lbs

Do your pets live indoors, outdoors, or indoors/outdoors?

Skip to next question for cat colonies.

Indoor onlyOutdoor onlyIndoor/Outdoor

Cat colonies: If assistance is being sought for outdoor cat colonies, please explain details of colony below.

For example, indicate the colony's location, number of cats, what you are currently feeding, etc.

Are all of your pets spayed or neutered?

Yes, all of my pets have been spayed/neutered.No, my pets are not spayed/neutered.Some of my pets are spayed/neutered.

If your pets are not spayed/neutered, do you intend to get them spayed/neutered?

Yes, but I cannot afford it now and need help to get my pets spayed/neutered.No. I do not plan to have them spayed/neutered at this time.All my pets are already spayed/neutered.Yes, I plan to get them spayed and neutered when I am able.

Please provide the name and phone number of the veterinarian or veterinary practice that you most recently have used.

If you do not have a veterinarian, please write "N/A" in the space below.

Please explain what types and brands of foods you currently feed your animals. Please note that we may not be able to provide you the same brands that you are currently using.

Be as specific as possible, for example, Purina One Urinary Tract dry cat food or Pedigree Choice Cuts in Gravy wet dog food.

Are there any non-food items that you need help with, for instance, flea and tick preventatives, medications, litter, etc.?

Please list items below.

Please list in general terms all of the food and other items for which you are requesting our assistance?

For example: cat food (dry), litter (scoopable), flea treatment (dog), etc.

Applicant's Information

Please share as much as possible with us about your current financial situation so that we can make an informed decision on your eligibility.

Please briefly explain your current situation and why you are requesting assistance through the ResQ Pantry.

Please include information like your current job status (unemployed, employed, retired, student, part-time, disability etc.) or recent change(s) to your income which have led you to need assistance at this time.

Do you currently receive any Human Social Service Assistance? Check all that apply:

SNAPDisability/SSIMedicaidUnemploymentWICI am currently not receiving any assistance, but am still suffering financial hardship.Other (explain at the end of the application)

How long do you anticipate needing the ResQ Pantry assistance?

1-3 months3-6 monthsI will likely need continued help as my financial situation is unlikely to change.Other (explain at the end of the application)

Please upload any documents showing financial need, such as unemployment status, disability, social security, SNAP etc.

Do not skip this step. Please provide a screen shot of a document that shows your participation in any of these programs. Your application will not be processed if you have checked that you receive benefits, but have not provided proof.

What is your current living situation?

Please explain whether you own or rent your home, are living with family, living in a hotel, are homeless, etc. This will help us determine whether we will be able to deliver items using internet or store services or have to physically deliver items to your place of residence.

Consent to ResQ Pantry Guidelines and Policies

Please complete this section to agree to our polices and requirements to receive aid.

Please check each of the five (5) boxes below to indicate your agreement. Failure to check every box and agree to each statement may affect your application approval.

I agree not to resell, redistribute or attempt to return to a store, any food or care items received from the ResQ Pantry.I understand that all pet food and supplies are donated and may not be the current brand I use to feed my pet(s).I agree not to add or replace any pets to my household while participating in the ResQ Pantry. I understand that if I do, my enrollment will be terminated.I agree not to hold The ResQ Pantry, To the ResQ, or any of its volunteers and benefactors legally liable in the unfortunate event my pet(s) become ill or have issues related to the food change.I agree not to use my pets for breeding or illegal activities.

If you do not receive help with your pets, what are your plans?

I would surrender them to our local shelter, because I will be unable to care for them.I would look for a rescue that could take them and find them homes, because I will be unable to care for them.I will keep looking for a solution so that I can keep my pets.

Please enter today's date:

Please enter your date of birth, including day, month, year.

For instance, April 24, 1968

By signing below, I attest that the information provided is truthful. The undersigned hereby releases To the ResQ, The ResQ Pantry and all representatives associated therein, from any and all liability related to the consumption/use of any pet food and/or care items provided. Typing my full name below serves as my signed agreement to and understanding of all of the requirements and statements as indicated in ResQ Pantry program guidelines.

If you need additional space for answers to any of the questions above, or would like to ask us a question, please use the space below.