Pet Food Pantry & Microchip Clinic
Our Pet Food Pantry is here to help neighbors facing hard times. If you’re struggling to afford food for your pets, we’re here to help supplement your pets' meals. This pantry event is also offering FREE microchips and core vaccines for your pets. Please complete the registration form below for each pet. All information will be used to register your pet's microchip. Finally, please note that ALL pets will be microchipped.
Contact Information:
This information will be used to register your pet's microchip. Please ensure all your information is accurate. If your pet is ever lost from home, this information is how they can get back home to you!
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Contact
Alternate Contact Name
*
First Name
Last Name
Alternate Contact Relation to You
*
Spouse/Significant Other
Relative (Parent, Sibling, Cousin, etc)
Friend
Neighbor
Other
Alternate Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Contact Email Address
example@example.com
Alternate Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Contact
Alternate Contact Name
First Name
Last Name
Alternate Contact Relation to You
Spouse/Significant Other
Relative (Parent, Sibling, Cousin, etc)
Friend
Neighbor
Other
Alternate Contact Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Contact Email Address
example@example.com
Alternate Primary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Time Slot
*
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How many dogs live in your home?
*
How many dogs will you be bringing to this FREE event for services?
What services does your dog(s) need? Note that all dogs WILL be microchipped, if not already!
Core Vaccine (Distemper/Parvo)
Microchip
Pet Food
Other Supplies
How many cats live in your home?
*
How many cats will you be bringing to this FREE event for services?
What services does your cat(s) need? Note that all cats WILL be microchipped, if not already!
Core Vaccine (FVRCP)
Microchip
Pet Food
Other Supplies
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Pet's Name
Species
Dog
Cat
Breed(s)
Color(s)
Estimated Age
Pet's Date of Birth (if known)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dog Size
Small (under 25 lbs)
Medium (25-50 lbs)
Large (51-100 lbs)
Cat Size
Small (under 2)
Medium (2-8 lbs)
Large (8+ lbs)
Sex
Female
Male
Is your pet spayed or neutered (fixed)?
Yes
No
Unknown
Any special notes of information regarding this pet?
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Do you have any non-cat/dog pets (such as birds, rabbits, reptiles, etc.)?
Yes
No
Are all of the pets in your household spayed/neutered (fixed)?
Yes, all are spayed/neutered
No, none are spayed/neutered
Some are spayed/neutered
I'm not sure
Would you like to be contacted about spay/neuter resources?
Yes, please email me.
Yes, please call me.
Not at this time.
Staff Use Only:
MEDICAL INFORMATION SECTION
Microchip Implanted:
If you implanted a microchip to the pet, enter the number here.
Microchip Found:
If you FOUND a microchip in this pet, enter the number here.
DAPP
DAPP (For Dogs - Distemper, Adenovirus, Parainfluenza, Parvovirus)
FVRCP
FVRCP (For Cats - Feline Viral Rhinotracheitis, Calicivirus, Panleukopenia)
FOOD DISTRIBUTION SECTION
Dog Food Preferences:
Wet food only
Dry food only
Wet or dry food
Food for a puppy
Food for a senior dog
Food for small breeds
Food for large breeds
Specialty diet
Pounds of dog food given:
Portioned bags of dog food given:
Cans of dog food given:
Cat Food Preferences:
Wet food only
Dry food only
Wet or dry food
Food for a kitten
Food for a senior cat
Specialty diet
Cat litter
Pounds of cat food given:
Portioned bags of cat food given:
Cans of cat food given:
Pounds of cat litter given:
Other supplies given:
Information on S/N
Information on microchipping
Leash
Collar
Toys
Litter box
Bowls
Shampoo
Cleaning Products
Any other supplies or notes about this distribution?
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I certify that: I am 18 years of age or older; I am the owner of the pet listed above; and I have verified the information provided on the registration form is accurate.
Yes
By submitting this form, I understand that my pet will receive a microchip if they do not already have one.
Yes
I understand the information provided on this form will be used to register my pet's microchip, and I consent to the release of my information for reunification purposes to private citizens or animal welfare organizations who might find my pet.
Yes
I consent to Aggieland Humane Society using photographs taken of me/my pet for promotional purposes on their website and social media pages.
Yes
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: