Emergency Food & Supply Request

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Humane Society of Davie County reserves the right to track recipients of food pantry donations for funding, grant, and record keeping purposes. Humane Society of Davie County reserves the right to limit amount of food received based on, but not limited to, proof of animals in recipients care, size and/or age of animals, as well as amount received by recipient in the last 90 days.

Name *

Full name as listed on license or other form of identification.

License and/or Form of Identification Number *

Please enter state and driver's license number (or ID number on other form of identification).

Do you have transportation to meet a staff member to pick up the food? *

Yes

If no, what is your address for Driveway Drop Off? *

Please enter your email to receive updates regarding food pantry such as reminders or whether or not you have received your quarterly limit of food and/or supplies.

Phone Number

Does HSDC have permission to send you a text message to confirm supply drop off? *

Yes

What type of pet food do you need? *

Please note that following your first recorded receipt of food pantry an HSDC staff member will be contacting you to create a record of animal(s) in the home. Information collected may include: pet name; pet age; pet breed. Other information may be requested to confirm that all community members have equal opportunity at food pantry donations.

Dog Dry Food

Dog Wet Food

Cat Dry Food

Cat Wet Food

Required

Other Supplies Needed (if available)

Beds (for indoor use)

Blankets (for indoor use)

Dog House (for outdoor use)

Cat House (for outdoor use)

Outdoor Shavings (for outdoor use)

Litter

Other:

Please list each pet benefiting from the Pet Food Pantry. *

Please include the following information:

Name

Age

Cat or Dog

Dog's Weight

Release Agreement *

I agree to accurately and honestly report animals in my care to the Humane Society of Davie County. I agree to notify the Humane Society of Davie County to changes of animals in my care such as the addition of animals or notify them of animals that are no longer in my personal care receiving services from the Food Pantry of HSDC at the time that the number changes. I understand that if the Humane Society of Davie County becomes aware of falsified information, they have the right to refuse any or all future assistance with regards to food and/or supplies received by animals in my care. I understand that these terms could change at any time and that the amount of food and/or supplies received from the Humane Society of Davie County could change at any time without warning based on available supplies, the amount previously received in last 90 days, and/or for other circumstances out of my control based on standards and policies of the Humane Society of Davie County. I release Humane Society of Davie County, volunteers, directors, and employees from any and all claims arising out of or connected with the Food Pantry of the Humane Society of Davie County. I agree that I have not and will not claim any right of compensation from them or file action by reason in regards to receipt of food and/or supplies, the amount (or lack thereof) food received, or the time frame and/or dates the food pantry is available to the public from the Humane Society of Davie County. I understand that personal and individual requests will not be granted in regards to date/time of Food Pantry as well as type of food available at the Humane Society of Davie County’s Food Pantry. By the electronic typed signature of my name below as listed on my form of identification and identification information provided previously, I agree to the above listed terms in regards to the Humane Society of Davie County’s Food Pantry.

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