foodbank application

Sophie's Circle Pet Food Pantry Application
for Temporary Pet Food Assistance

New Regulations Effective January 31, 2011

Please complete and submit the form below to be considered
for Sophie's Circle Pet Food Pantry assistance.
All information submitted here will remain confidential. Any
false information on this application will result in denial of
assistance.

The purpose of Sophie's Circle Pet Food Pantry is to provide
pet food for household animals who are family pets and who
are spayed and/or neutered. Therefore, we cannot provide
assistance for feral cat colonies, rescue organizations or
breeders.

To qualify for assistance, applicant must:
o Be 18 years or older and live in Volusia County, Florida
o Complete a new application for assistance if the number of
pets changes in the household or if there is a change of address
o Understand that the food provided through the service may
not match current brand, therefore, pet(s) may experience
stomach upset initially due to the change in diet,
o Show proof that pet(s) are spayed or neutered (CCFAW can
provide this service at a reduced charge along with low-cost
vaccinations at the time of surgery to pets of qualified individuals
that are not already altered). Families who don't wish to have
their pets spayed or neutered are ineligible for this program.
If pets are not spayed or neutered, show proof that an
appointment is set for the procedure.

Sophie's Circle Pet Food Pantry Guidelines:
o Food is distributed to approved applicants on Wednesday
(between 10 a.m. and 2 p.m.) each week.
o Only one applicant per household.
" Minimum of .50 donation required.
o The quantity of pet food received will depend upon the number
of owned pets (cats and dogs only),
their size, and the available supply at the time of distribution.
o Requests for specific food types will be considered (i.e. senior,
large breed, etc.), however, Sophie's Pet Food Pantry will only be
able to provide what is available from donated supplies.
o Sophie's Circle Pet Food Pantry reserves the right to deny food
to anyone under any circumstances or to make exceptions based
on individual need.
o Food provided through this service may not be resold; if Sophie's
Circle Pet Food Pantry determines that food has been resold, the
household and each of its members will no longer benefit from the
program.
o Service recipients must pick up food from Sophie's Circle Pet Food
Pantry.
o Sophie's Circle Pet Food Pantry offers temporary pet food assistance;
this service is not intended to supply food permanently.

I HEREBY WAIVE, RELEASE AND DISCHARGE FOR MYSELF, MY HEIRS, PERSONAL REPRESENTATIVES, AND ASSIGNS ANY AND ALL RIGHTS, LIABILITY, CAUSES OF ACTION AND CLAIMS THAT MAY NOW OR
HEREAFTER ACCRUE TO ME OR WHICH I MAY NOW OR HEREAFTER ASSERT AGAINST SOPHIE'S CIRCLE PET FOOD PANTRY, ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, SUCCESSORS AND ASSIGNS FOR ANY INJURY, HARM OR LOSS SUFFERED BY ME, MY FAMILY OR AN ANIMAL RELATED TO OR ARISING FROM MY ACCEPTANCE OR USE OF FOOD RECEIVED FROM
SOPHIE'S CIRCLE PET FOOD PANTRY. By signing your name below, you are acknowledging that you understand and agree to all of the provisions above.

Signature of Applicant:_________________________Date: ____________

Name of Applicant (please print): __________________________________
SOPHIE'S CIRCLE PET FOOD PANTRY APPLICATION:
Applicant Name: ________________________________________________ Date: ___________
Address: ______________________________________________________
City and State: _______________________________________________
Daytime Phone Number: __________________
Alternate Phone Number: __________________

How many pets are in your household? _________
Please provide information about your pet(s):
Pet's Name: _________________________ Cat Dog Spayed/Neutered: Y / N
Breed: _______________________ Age: _________ Weight: _______ lbs.
Pet's Name: _________________________ Cat Dog Spayed/Neutered: Y / N
Breed: _________________________Age: _________ Weight: _______ lbs.
Pet's Name: ________________________ Cat Dog Spayed/Neutered: Y / N
Breed: _________________________ Age: _________ Weight: _______ lbs.
Pet's Name: _________________________ Cat Dog Spayed/Neutered: Y / N
Breed: __________________________Age: _________ Weight: _______ lbs.

How did you hear about Sophie's Circle Pet Food Pantry? ________________________________
I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUE AND THAT GIVING ANY FALSE INFORMATION WILL RESULT IN THE DISAPPROVAL OF THIS APPLICATION AND FUTURE DISQUALIFICATION FROM THE SERVICE.
Signature: ___________________________________ Date: _____________

FOR SOPHIE'S CIRCLE PET FOOD PANTRY USE ONLY
Application Processor: ______________________Date: _________________
_____ Approved ____ Disapproved
Reason if not approved: ___________________________________________
Amount of food provided today:
______ Cat Food _______ oz. / lb. / cups
______ Dog Food _______ oz. / lb. / cups
Type of food provided (check all that apply):
___ Dry Cat Food ___ Wet Cat Food ___ Dry Dog Food ___ Wet Dog Food
Brand of food provided (write all that apply):
______________________________________________________________
Comments: ______________________________________________________________