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Paws & Plates Food Pantry Application

Name

Address

City

Zip

Area of Residence

A
B

Phone

Email

Reason for Financial Need

Do you need food for your cat(s) or dog(s)? Choose one

I agree to appear in person and provide valid photo identification and proof of income to verify my identity and financial status.


I understand that this is a free and voluntary service and by making my request I am committing to picking up my order at the time selected above. Should I fail to meet my commitment pick up time, follow any rules set forth, speak or act in a way that is unbecoming or threatening, or for any other reason specified, Panola County Dog Rescue may remove me from the program at will.

I understand that Panola County Dog Rescue has a limited amount of food available for animals in need; 2) the amount of food provided will be determined on a case by case basis, depending on availability and need; 3) a representative will establish a date and time for me to receive the allocated food; 4) based on demand, I will only receive a limited amount of food and Panola County Dog Rescue cannot guarantee how much or how often it can provide food to me for the animals in my care.


I recognize that in receiving assistance in the form of donated pet food there exists risk of injury or sickness, including personal injury or harm to me, my pet(s) and others. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify, and hold harmless Panola County Dog Rescue, and its agents from any and all claims, causes of actions of demands, of any nature or cause connected with my receipt of assistance in any form from Panola County Dog Rescue.

Signature