Kibble Konnection Application
Humane Society of West Michigan is proud to operate the Kibble Konnection, a pet food bank program which helps low-income pet owners provide food for their pets, in partnership with the Access of West Michigan Food Pantry network. To qualify for the program, pet owners must be able to provide what kind of assistance they receive (for example: Medicaid, Social Security, Disability, Unemployment, etc.), photo id, and pets must be spayed or neutered. This is a dry food only program and we cannot fill specific brand/food products. This program is to supplement food and is not intended to be your entire pet food supply. Additionally, we are only able to provide food for TWO animals per household.
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Requirements & Other Information
Owner's Information
Please fill out below fields.
Date
*
-
Month
-
Day
Year
Date
Owner's First Name
*
Owner's Last Name
*
Main Phone:
*
-
Area Code
Phone Number
Addional Phone:
-
Area Code
Phone Number
E-mail:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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1st Pet's Information
Name of Pet
*
Type of Pet (Ex: Dog, Cat..)
*
Breed of Pet
*
Color
*
Age
*
Gender
*
Female
Male
Spayed/Neutered
*
Yes
No
Unkown
Length of Time Owned
*
Weight of Pet
*
Small 5-30lbs
Medium 31-71lbs
Large 71lbs+
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2nd Pet's Information
If you do not have any more pets please skip this page.
Name of Pet
Type of Pet
Dog
Cat
Breed of Pet
Color
Age
Gender
Female
Male
Spayed/Neutered
Yes
No
Unkown
Length of Time Owned
Weight of Pet
Small 5-30lbs
Medium 31-71lbs
Large 71lbs+
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3rd Pet's Information
If you do not have any more pets please skip this page.
Name of Pet
Type of Pet
Dog
Cat
Breed of Pet
Color
Age
Gender
Female
Male
Spayed/Neutered
Yes
No
Unkown
Length of Time Owned
Weight of Pet
Small 5-30lbs
Medium 31-71lbs
Large 71lbs+
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Spay/Neuter Proof
*
Browse Files
*You MUST attached documentation as proof of surgery for each animal listed above. Current Vet of clinic that performed the surgery can provide this to you. Application will not be processed without this proof.*
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Assistance
To be eligible for the Kibble Konection program, you must qualify as low income, be a current participant in state/federal assistance program, or experiencing financial hardship.
What kind of assistance do you receive (for example: Medicaid, Social Security, Disability, Unemployment, etc.)
*
What kind of assistance do you receive (for example: Medicaid, Social Security, Disability, Unemployment, etc.)
*
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By signing, I am declaring that the information on this application is correct and that I have read and agree to the Kibble Konnection membership terms. I understand that HSWM Kibble Konnection program is intended as a supplemental food source only and is not the sole source of food for my pets. Membership is valid for 1 year. I understand I will need to reapply every 1 year in order to remain a member and received food distributions. HSWM strongly encourages animals to be spayed or neutered. I agree not to breed my pets or acquire more pets while I am receiving food from this program. I release HSWM from any claims, liability or damage relating to food I receive through HSWM Kibble Konnection program, and I waive my right to raise any claims against HSWM relating to HSWM Kibble Konnection program or food I receive through that program. I understand that communication may be sent electronically via email. It is my responsibility to check my email for Kibble Konnection updates, information, re-applications, etc. Signature
*
Clear
Please verify that you are human
*
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HSWM USE ONLY
Bridge Card
Medicaid
Unemployment
SSI
Disability
Income Verification
Other
Low Income Letter Date
Client Notified Date
Client #
Pantry
Pantry Notified Date
Client List
Compliant
Non-Compliant
Other Notes
Submit
Should be Empty: