Lennoxs Legacy Rescue, Inc.

Adams County Pet Food Pantry, Inc.

Sponsored by Lennoxs Legacy Rescue, Inc.

Decatur, IN 46733

Ph. 260-227-0107

Email: lennoxslegacy@live.com

 

Application for Assistance

 Pet Owner’s Information (list anyone who could pick up food for you)

 

Owner’s Name:________________________________________________  Other Name(s):_________________________

Street Address:_______________________________________________  

City, State, Zip:________________________________________________                  Phone # _________________________

 
Proof of Identity and Address (please bring BOTH of the following):        ___ Photo ID         ___ a current utility bill

 
Proof of Financial Hardship (please bring ONE of the following):       ___Unemployment        ___Social Security       ___Disability ___Medicare/Medicaid      ___Other (food stamps, WIC, Care Credit, Meals on Wheels, etc)            ___Pay Stub

 
Pet’s Information

(AC Pet Food Pantry strongly encourages that pets are spayed/neutered)

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No Veterinarian:_________________________________

 
 Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 

Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 
Name:______________________________________                                ___ Dog   or   ___ Cat        Age: ______

 Breed if known:_______________________________                     If female, is she spayed?   ___Yes   or   ___No         

                                                                                                                        If male, is he neutered?   ___Yes    or   ___No
Veterinarian:_________________________________

 I attest that all information provided to Adams County Pet Food Pantry is accurate and complete. I understand that all distribution of foods is based on availability and that products distribution is on a first come first served. ACPFP cannot guarantee the brand or availability of pet food.

 Signature ____________________________                               Date ____________________________

 
ACPFP Volunteer ______________________                              Date ____________________________

PLEASE PRINT, READ, COMPLETE AND SIGN. YOU MUST BRING WITH YOU TO THE DISTRIBUTION!



Adams County Pet Food Pantry

Sponsored by Lennoxs Legacy Rescue, Inc.

Decatur, IN 46733

Ph. 260-227-0109

Email: lennoxslegacy@live.com

 

Guidelines for Receiving Pet Food Assistance

 Adams County Pet Food Pantry (ACPFP) provides free pet food to people who are struggling financially and cannot afford to feed their pets. If you are able to provide for your pets, then please leave this food for those pets who are less fortunate than your own.

 All recipients of products from ACPFP acknowledge, understand, and consent to the following terms of this program:

 Applications will be reviewed once a year to see if you still meet the requirements for assistance.

 Change of address should be brought to ACPFP’s attention right away so your file can be updated at that time.

 If your number of pets decreases or your financial situation improves, you agree to notify ACPFP on your next visit. You also agree to not actively search for additional pets.

 Only one application will be accepted per address.

 Applicants may receive pet food on their first visit without prior approval, but must have an approved application within one month of their first visit.

 In order to receive food from ACPFP Spay/neuter is required. Information can be provided on low cost spay/neuter program assistance through SNSI of Indiana.  

 ACPFP is a supplemental pet food program and most likely will not be able to provide enough food to feed all of your pets until the next distribution date.

 Since the food we provide is based on donations, we cannot guarantee the brand or amount of food that will be given each time. Brands may vary from week to week, therefore your pet(s) may experience stomach upset due to the change in food. Requests for special types of food will be considered but not guaranteed. Amount of food given may vary from month to month depending on available supply.

 Pet food may have recent expiration dates but is still suitable for consumption to the best of the pet food pantry’s knowledge.

 ACPFP receives notifications on pet food recalls and will notify patrons to the best of our ability if there is a possibility recalled food was given out. However, we cannot guarantee that patrons will be notified prior to giving the food to their pets. You can visit http://www.fda.gov/AnimalVeterinary/SafetyHealth/RecallsWithdrawals/default.htm to access the FDA’s link to the latest recalls.

 Food received from ACPFP cannot be resold. Doing so will result in immediate termination of our services.

 Other pet related items such as toys, treats, cat litter, bedding, cages, crates, clothing, bird food, etc. are donated and are not available every time. These items as well as dog and cat food are all distributed on a FIRST COME FIRST SERVE basis. Quantities per person may be limited so that we may serve as many as possible.

 ACPFP is typically open one Saturday per month from 12-2pm . Dates are scheduled ahead of time and can be found on our facebook page.

 ACPFP reserves the right to reschedule distribution dates, times, or location in the event of a scheduling conflict or holiday. Changes are typically made in advance and communicated to patrons at distribution, as well as our facebook page.

 If your application has been approved, and there comes a time that you are unable to pick up your own food, you may send someone else in your place but they must bring a note signed by you confirming your name, address, how many pets you have, and reason for not coming. This practice should be an exception, and not the rule.

 We ask for a small donation that you can afford but do not require it. Giving back with your time and volunteering with us is another way to say thanks and help us help others.

 All recipients must agree to not have any animal outside, on a rope or chain, 24 hrs a day, 7 days a week.

 All recipients with dogs agree to not participate in any dog-fighting related activities. Discovery of this activity will guarantee an immediate report to law enforcement. DOGFIGHTING IS ILLEGAL AND INHUMANE!

 ACPFP provides assistance only with pet food. We do not possess medical training and cannot diagnose your pet(s) symptoms or injuries. We will do our best to refer you to other organizations that may be able to help you.

 ACPFP is not a law enforcement agency; however, if we suspect an animal is being abused, neglected, or otherwise receiving inadequate care, we reserve the right to contact law enforcement officials which could lead to an investigation which may include a home visit.  

ACPFP will share pet owner’s information with authorities as needed.

You agree to allow someone at ACPFP to visit and inspect your pet’s condition and environment at any time.

ACPFP reserves the right to refuse assistance to animal breeders, puppy mills, or animal hoarders.

 ACPFP reserves the right to terminate or deny pet owners from this program at our discretion.

Providing false information will result in denial of assistance.

 ACPFP reserves the right to change the terms of this program without prior notice to pet owners.

 

Please read the following carefully:

 By signing this page, I agree to abide by the above guidelines set forth by Adams County Pet Food Pantry (ACPFP), and I understand that ACPFP reserves the right to change these guidelines as needed to best serve their patrons and their pets. I understand that ACPFP is intended to be a supplementary source of pet food and is not equipped to be the sole source of food for my pets. I agree to request food only as needed so that those who are less fortunate than me may be served.

 Liability Release (Required)

 I, ________________________________understand that by signing and agreeing to this statement, I agree that the items provided to me; food, treats, or any other supplies provided to me to me by Adams County Pet Food Pantry, are free of foreign and/or harmful objects that could hurt or cause injury to my pet(s). In the event that my pet(s) become ill or perishes, I fully release Adams County Pet Food Pantry and all volunteers and staff from any legal, financial or civil liberties.

 

Print Name:_________________________________________                                                                              

 

Sign:______________________________________________         Date: _________________________________________