Shoe Request Form

* Child's name

* Age (must be between 5 and 18)

* Gender

* Shoe size

* Shoe width

* Specify sizing

* Person to contact

* Relationship to child

* Street address

* City

* State and zip code

* Phone

* Email

* How did you hear about us?

*

Activity Requirement
We are so happy for the opportunity to provide shoes to those in need! We are asking all recipients to make a pledge upon shoe delivery to be active 30 minutes a day, 5 days a week. This activity time will be in addition to regularly scheduled recess and PE. Registration for the Healthy Kids Run Series (ages 5-12) or the Fit.Teen Run Series (ages 13-18) is also required. Most events are free and kids earn prizes, depending on how many events they participate in. For more information on the Run Series, please visit https://vic.pvhs.org/portal/page?_pageid=333,429685&_dad=portal&_schema=PORTAL&pagid=137

Do you accept these terms?

yes

no

* Income Requirements
In order to serve those who need shoes most, we require that your income falls within the following guidelines. To determine family size and income, include everyone living in your household.

Family Size	Monthly Gross Income
2	below $2490
3	below $3128
4	below $3767
5	below $4406
6	below $5045
7	below $5684
8	below $6323
9	below $6962
10	below $7601
10+ (add $639)

Do you meet this requirement?

yes

no

We are a new organization and are currently gathering our resources. We will fill your need as soon as we possibly can, but there may be a wait period at this time. We thank you for your patience and for the opportunity to serve you!

All of your information will be kept strictly confidential.

Comments/Other information

* Indicates Response Required