Application for Pet Food

Contact Information

First Name (required)

Last Name (required)

Address (required)

Address 2

City (required)

State (required)

Zip Code (required)

Date of Birth (required)

Main Phone (required)

Secondary Phone

Email

Do you live in a secure building? (required)
YesNo

Eligibility

** In order to be eligible for Cedar Rapids AniMeals you must have a caseworker at a Social Service Agency OR receive federal benefits.

Do you have a caseworker at a Social Service Agency? (required)
YesNo

Please have your caseworker provide the Referral from a Social Service Agency listed below.

Agency Name

Caseworker Name

Phone

If you do not have a caseworker at a Social Service Agency, which of the following benefit(s) do you receive? Please check the appropriate box(es).
SSI-Supplementary Security Income - You must provide current year's Social Security Proof of Income (Benefits) Letter to receive services. Please mail to Cedar Rapids AniMeals.SSDI-Supplementary Security Disability Income - You must provide current year's Social Security Proof of Income (Benefits) Letter to provide services. Please mail to Cedar Rapids AniMeals.SS-Social Security - You must attach current year's Social Security Proof of Income (Benefits) Letter to provide services. Please mail to Cedar Rapids AniMeals.

Companion Pet Information

Total number of pets in your household (required)

**Cedar Rapids AniMeals will provide for up to two pets (cats or dogs only) in a single household. Please indicate companion pet(s) to receive services.

Companion Pet #1

Pet Name (required)

Type (required)
DogCat

Age (required)

Weight (required)

Color

Breed or Description (required)

Sex (required)
FemaleMale

Spayed/Neutered (required)
YesNo

If female and not spayed, is she currently pregnant?
YesNo

If pregnant what do you intend to do with the litter?

Are you interested in having your companion pet spayed or neutered?
YesNo

Do you have a second companion pet?
YesNo

Companion Pet #2

Pet Name (required)

Type (required)
DogCat

Age (required)

Weight (required)

Color

Breed or Description (required)

Sex (required)
FemaleMale

Spayed/Neutered (required)
YesNo

If female and not spayed, is she currently pregnant?
YesNo

If pregnant what do you intend to do with the litter?

Are you interested in having your companion pet spayed or neutered?
YesNo

Privacy Statement and Liability Waiver

I consent to the use of the attached evidence of eligibility to be used by Cedar Rapids AniMeals to verify my eligibility for enrollment in Cedar Rapids AniMeals programs. I understand that this information is confidential and will be used by Cedar Rapids AniMeals only for the purposes of establishing my eligibility for the programs.

I agree to hold Cedar Rapids AniMeals, its directors, officers, employees, volunteers, and any party or employee of the aforementioned parties, harmless from any claim or loss which may be alleged to have been caused directly or indirectly to any person, animal, or things while a client of Cedar Rapids AniMeals.

I hereby certify that the information I have entered on this application is accurate and true.

I hereby certify that I have read, understand, and agree to the terms and conditions stated in the Cedar Rapids AniMeals Application for Enrollment.

I accept this agreement

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