Clone of Kicks for Kidz Sneaker Giveaway Application

Kicks for Kidz Sneaker Giveaway Application

Apply to receive brand new sneakers for your children. Have your family details ready and note that selection depends on need and available sizes.
Parent/Guardian Information
Full Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP Code
Child Information
Child Entries
Child information may be added for more than one child.
Family Need
Briefly tell us why your family is applying for sneaker assistance
Number of children in household
Do you currently receive public assistance or community support?
Has your family received support from She Speaks Community Co. before?
Event Pickup
Selected families will receive pickup instructions before the June 27 It Takes a Village event at Fred Fletcher Park in Raleigh, NC.
Able to attend the June 27 event?
If no or not sure, please explain
Authorized pickup person name (if different from parent/guardian)
Authorized pickup person phone
Please enter a valid phone number.Format: (000) 000-0000.
Consent & Acknowledgment
Acknowledgment of application outcome
Acknowledgment of donation and size availability
Information accuracy confirmation
Permission to contact me
Media permission
Signature
Parent/Guardian Electronic Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Kicks for Kidz Sneaker Giveaway Application