Pet Pantry Program

Thank you for your interest in receiving assistance from HSSV’s Pet Pantry Program, which is 100% supported by community donations. Special Thanks to The Health Trust and Farrington Historical Foundation for providing funding for this program.

Our goal is to ensure that families who love their pets don't have to feel stressed about feeding them or providing basic care, even in times of need. These families are defined as "bonded families."

Pet Pantry is available to all bonded family residents of Santa Clara county experiencing financial hardship.

Please be advised that we are not able to accept cat colony clients at this time.

Fill out the information below to get started.

First Name *

Last Name *

E-mail address *

Address *

City *

State/Province *

Zip Code *

Home Phone Number *

Please enter as (111) 222-3333

Mobile Phone Number

Please enter as (111) 222-3333

Authorized Alternate for food pickup

Please help us learn more about the pet(s) in your family:

# of cats in your family

# of dogs in your family

Pet #1 Information

Pet Name

Species

Cat

Dog

Gender

Female

Male

Pet Age

Pet Weight in pounds

I am interested in receiving the following medical services for my pet at no cost to me (please select all services that apply)

Vaccinations

Spay/Neuter Surgery

Both Vaccines and Spay/Neuter Surgery

No thanks

Pet #2 Information

Pet Name

Species

Cat

Dog

Gender

Female

Male

Pet Age

Pet Weight in pounds

I am interested in receiving the following medical services for my pet at no cost to me (please select all services that apply)

Vaccinations

Spay/Neuter Surgery

Both Vaccines and Spay/Neuter Surgery

No thanks

Pet #3 Information

Pet Name

Species

Cat

Dog

Gender

Female

Male

Pet Age

Pet Weight in pounds

I am interested in receiving the following medical services for my pet at no cost to me (please select all services that apply)

Vaccinations

Spay/Neuter Surgery

Both Vaccines and Spay/Neuter Surgery

No thanks

Pet #4 Information

Pet Name

Species

Cat

Dog

Gender

Female

Male

Pet Age

Pet Weight in pounds

I am interested in receiving the following medical services for my pet at no cost to me (please select all services that apply)

Vaccinations

Spay/Neuter Surgery

Both Vaccines and Spay/Neuter Surgery

No thanks

Pet #5 Information

Pet Name

Species

Cat

Dog

Gender

Female

Male

Pet Age

Pet Weight in pounds

I am interested in receiving the following medical services for my pet at no cost to me (please select all services that apply)

Vaccinations

Spay/Neuter Surgery

Both Vaccines and Spay/Neuter Surgery

No thanks

For any additional pets please provide the following: Name, Species (dog/cat), age, weight.

I'm unable to pick up my food due to health or transportation issues *

Yes

How did you hear about Pet Pantry?

Program Guidelines for Program Participants:

· Please notify the HSSV team in the event that you no longer need support so that others may be helped.

· Food distribution is every 30 days during Pet Pantry designated hours. Shorter exceptions or alternate pick up times may be arranged with prior discussion with HSSV.

· Photo identification will be shown to staff for our records.

· Food will be provided only if HSSV has food to distribute. Support given through this program is dependent on community donations.

· Prescription diet food is not available at this time.

· HSSV cannot guarantee support of additional pets that are acquired after entry into the program.

· Please do not sell, give away, or return to a store any pet food or supplies received through the Pet Pantry.

· HSSV reserves the right to discontinue service through its Pet Pantry program at any time, for any reason.

By electronically signing below, you understand and agree to all of the requirements and statements as indicated in our program outline. Please write your name and the date as your signature.

Signature Name *

Signature Date *

Email Opt-out

Yes, I would like to receive email communications from HSSV

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