Language
English (US)
Spanish (Latin America)
Appointment Time
*
Parent Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
May we send an automatic text reminder?
*
Yes
No
Do you speak English?
*
Yes
No
What school does your child / Children attend?
*
Please Select
Manteo Elementary
First Flight Elementary
Nags Head Elementary
Kitty Hawk Elementary
Cape Hatteras Elementary
How many elementary aged children need an appointment?
*
Please Select
1
2
3
4
(If more than four, please make another appointment for the following time)
Child 1
Gender
*
Please Select
Male
Female
Grade Level
*
Please Select
Pre K
K
1st
2nd
3rd
4th
5th
Size
*
Please Select
4-5
5-6
6-7
7-8
8-10
10-12
12-14
14
16
Other
Shoe Size
*
Please Select
11
12
13
1
2
3
4
5
6
7
8
9
10
We are working towards building shoe inventory and will try to accommodate those with a significant need.
Child 2
Gender
Please Select
Male
Female
Grade Level
Please Select
Pre K
K
1st
2nd
3rd
4th
5th
Size
Please Select
4-5
5-6
6-7
7-8
8-10
10-12
14
16
Other
Shoe Size
*
Please Select
11
12
13
1
2
3
4
5
6
7
8
9
10
We are working towards building shoe inventory and will try to accommodate those with a significant need.
Child 3
Gender
Please Select
Male
Female
Grade Level
Please Select
Pre K
K
1st
2nd
3rd
4th
5th
Size
Please Select
4-5
5-6
6-7
7-8
8-10
10-12
12-14
14
16
Other
Shoe Size
*
Please Select
11
12
13
1
2
3
4
5
6
7
8
9
10
We are working towards building shoe inventory and will try to accommodate those with a significant need.
Child 4
Gender
Please Select
Male
Female
Grade Level
Please Select
Pre K
K
1st
2nd
3rd
4th
5th
Size
Please Select
4-5
5-6
6-7
7-8
8-10
10-12
12-14
14
16
Other
Shoe Size
*
Please Select
11
12
13
1
2
3
4
5
6
7
8
9
10
We are working towards building shoe inventory and will try to accommodate those with a significant need.
In School Appt?
Yes
Shoes Needed
Yes
Coat Needed?
Yes
Child 1 Name
Teacher
Submit
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