Please complete one form for each child. Deadline for submission is Wednesday, August 18, 2021. Parent Name First Last Organization Name (if applicable) Delivery Address(Required) Street Address City State / Province / Region ZIP / Postal Code Contact Email(Required) Contact Phone Number(Required) Child's Name(Required) Your child's name is for internal use only. We will assign an ID# for each child which will be given to a donor so we can match shoes purchased with your child's ID#.Child's Age(Required)Child's Gender(Required) Male Female Other: Child's Shoe Size(Required)Child's Shoe Size by Age(Required) Toddler Youth Adult Preferred Shoe Style(Required) Tie Velcro Slip-on Shoe color or character preference (not guaranteed):(Required) Additional information or notes: Please check if you are interested in information about other JFS services: Counseling Support Groups Case Management Food Security Reading Buddies Other: We appreciate you taking the time to complete this form. Please remember that all submissions are confidential. If you need any support that is not listed here, please be sure to add it under "other" and we will reach out to notify you of our available resources.Please note: our ability to fulfill requests for shoes is contingent on donations from the community. We will contact you immediately if we cannot fulfill your request.