School Shoe Referral Form
Please provide details to refer students in need of shoes
School District
*
Please Select
KIPP NC
Roanoke Rapids City Schools
Weldon City Schools
Nash County Public Schools
Edgecombe County Schools
Wake County Schools
Halifax County Schools
Northampton County School
Rocky Mount Preparatory School
School Name
School Contact Name and Title
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact Email Address
*
example@example.com
Date of Referral
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Number
Grade
*
Student Age
*
Student Gender
*
Male
Female
Non-binary
Other
Shoe Type Needed
*
Little Kid
Youth
Men
Women
Student Shoe Size
Reason for Referral
*
No proper shoes
Shoes too small/torn
Homeless/temporary housing
Foster care/kinship care
Financial hardship
Other
Parent Consent
Please Select
Yes
No
Delivery Method
*
Delivery to school through social workers/counselors
Preferred Delivery Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Delivery Time
Hour Minutes
AM
PM
AM/PM Option
School Approval (Name/Title of Approver)
*
Staff Signature
*
Date Signed
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shoes-A-Million Office Use Only
For internal processing. Please complete after shoes are provided.
Date Received
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shoes Provided
Yes
No
Brand/Type of Shoes Provided
Date Delivered
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Received By (Name/Title)
Notes
Submit Referral
Submit Referral
Should be Empty: