Pet Pantry Application Roice-Hurst Humane Society (RHHS) strives to keep pets with their families whenever possible, recognizing how important pets are to overall well-being. Please read the following carefully and fill out the application to best of your ability. Thank you for your commitment to caring for your pet(s)!By clicking YES, Applicant understands that the purpose of the program is to "supplement, not sustain" feeding or care.* YES By clicking YES, Applicant understands RHHS cannot guarantee specific brands or amounts of food available. The RHHS Pet Pantry functions on a first come, first serve basis.* YES By clicking YES, Applicant understands the pet pantry can be accessed every other month. RHHS request that you do not obtain new animals while utilizing the pet pantry.* YES By clicking YES, Applicant agrees that RHHS, its donors, contributors, volunteers, staff members, or pet food manufacturers cannot be held responsible for any injury or illness of Applicants pet.* YES By clicking YES, Applicant agrees that a photo of the pet(s) will be taken by RHHS or provided to RHHS.* YES Pet Photo Drop files here or Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* How did you hear about this program?*Please tell us the reason you are seeking assistance. *If you choose to answer, your answers and identity will remain confidential. Roice-Hurst uses this information for data collection to obtain grant funding. You will not be denied access to the pet pantry based on your answers.HouselessUnemployedSenior citizenColony CaretakersOther - please explain.Pet 1* Cat Dog Pet 1 - Name, Age, Sex, Breed (if known)*Pet 1 - Spayed/Neutered* Yes No Unknown Pet 1 - Please check all vaccinations that your pet(s) has received within the last three years.* Select All Rabies Distemper/Parvo Bordetella Other None Pet 1 - Please list any allergies or special dietary needs.*Pet 2 Cat Dog Pet 2 - Name, Age, Sex, Breed (if known)Pet 2 - Spayed/Neutered Yes No Unknown Pet 2 - Please check all vaccinations that your pet(s) has received within the last three years. Select All Rabies Distemper/Parvo Bordetella Other None Pet 2 - Please list any allergies or special dietary needs.Pet 3 Cat Dog Pet 3 - Name, Age, Sex, Breed (if known)Pet 3 - Spayed/Neutered Yes No Unknown Pet 3 - Please check all vaccinations that your pet(s) has received within the last three years. Select All Rabies Distemper/Parvo Bordetella Other None Pet 3 - Please list any allergies or special dietary needs.Consent* I HEREBY WARRANT THAT I (A) AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND THE AGE OF MAJORITY IN THE STATE IN WHICH I RESIDE. I WARRANT and AFRIM THAT I HAVE ANSWERED THE ABOVE QUESTIONS TRUTHFULLY AND TO THE BEST OF MY KNOWLEDGE.CAPTCHANext StepsYou can expect a RHHS staff member to contact you within 48 hours (weekends excluded). Thank you!
