In-Home Services Assistance Form

This form is for supplemental, monthly pet food delivery for homebound pet owners who have no other assistance. Proof of disability is required for applicants.

Due to program limitations, pet food delivery services are reserved for households where residents are homebound due to disability and are unable to access our Pet Food Pantries. While we understand transportation challenges can make it difficult to obtain pet food, lack of transportation alone does not meet the eligibility requirements.

If you are looking for financial assistance, please visit: https://humanefw.org/wellness-assistance-application/

Approval and scheduling may take place between 1-5 business days depending on availability of our volunteer team. Thank you for allowing us to love your pets as much as you do!

Name(Required)

First Last

Date of Birth: (Required)

Phone Number(Required)

Email(Required)

Address(Required)

City(Required)

Zip(Required)

List all people living in the home who are over 18 and their Date of Birth:(Required)

List all pets in the home(Required)

Name, Age, Gender, Cat or Dog, Spayed or Neutered, and Breed

Describe your needs(Required)

If you need pet food, are you or someone you know able to attend one of our free distributions?(Required)

Pet Food Distribution Times/Dates: https://humanefw.org/get-help/pet-food-pantry/

Are you homebound?(Required)

If not, please explain why you need delivery or transportation assistance:

Release and Certification of Information:

For value received, I/we, the owner(s) of the above-designated cats and/or or dogs, do hereby fully and completely release and discharge Humane Fort Wayne and all persons, agents, employees, directors, and officers thereof and/or on its behalf liable from and against any and all actions, causes of action, claims, demands, assertions, contentions, suits, damages, expenses and/or losses of any kind and description which in any manner pertain to, concern, involve or relate to the care and medical treatment of my/our pet(s), including injury or death, and I/we agree to indemnify and hold harmless all entities and persons being released hereunder from and against any and all actions, causes of actions, claims, demands, assertions, contentions, suits, damages, expenses, and losses resulting from the foregoing activities. By my signature below I certify that I understand that all of HFW's assistance programs are for limited income pet owners only, and the information provided is accurate and complete, and that this information is subject to verification prior to approval.

Signature(Required)

Date(Required)

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In-Home Services Assistance Form

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