Impact Shoes Request Form
**Submission must be completed by Counselor/Social Worker from the Blue Springs & Lee's Summit R-7 School Districts
Counselor/Student Advocate Contact Information
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First Name
Last Name
Email
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example@example.com
I affirm and attest that I work for the following school district
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Blue Springs School District
Lee's Summit School District
Other
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Date
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Month
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Day
Year
Date
Student's School
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Student's Name or initials
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Student's age
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Student's Gender
Female
Male
Preferred delivery method
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Pick up at Woods Chapel Church 4725 NE Lakewood Way LS 64064
Deliver to student's school
Student's shoe size category
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Womens/Big Girls (big kids 3-6, women's 7-11)
Men's/Big Boy (big kids 3-6, men's 7-12)
Little kids (toddler, little kid 10c-2.5Y)
Student's shoe size according to shoe sizer
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Student should stand with heel resting against back of sizer. Please note the different columns to read based on men/wmn/kids.
Student's shoe width
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Medium-standard
Wide
Preferred shoe style - see attached shoe guide for examples
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Athletic/Training/Running/Playing style
Mid/High Top Basketball style
Fashion/leisure style shoe similar to Nike Court Vision
Converse/Vans - please note high vs low top in comment section
Crocs style shoe
Preferred BASE color or main color of the shoe?
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Example: mainly black shoe or bright neon color like pink
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Preferred ACCENT color- please list top two choices.
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How does your student describe their favorite shoe? What more can you tell us? Base color, accent color, sole color, brand suggestions? Slip on or velcro, sparkly, light up, all black? Completely white with no accent? The more details the better.
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Helpful examples: 1. student would love Nike shoes, low top, white base with blue or red accents- blue preferred 2. student would do best with velcro laces 3. student would love all black shoe, with black sole black everything
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Submit
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