Youth Shoe Assistance Referral Form
Share your referral details so SafeGround can review shoe availability and contact you if an appropriate size is available.
Referring Person Information
Referring Person Name
*
First Name
Last Name
Organization or School (if applicable)
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Relationship to Child
*
Please Select
Parent/Guardian
Teacher
School Counselor
Case Worker
Social Worker
Family Friend
Coach
Other
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
City
*
ZIP Code
*
Child Information
Child's First Name
*
Child's Age
*
Shoe Size
*
Shoe Size Type
*
Please Select
Little Kid
Big Kid/Youth
Women’s
Men’s
Is this the child's current shoe size?
*
Yes
No
Unsure
Child's Last Name
Assistance Need and Urgency
Does the child currently have a properly fitting pair of everyday shoes?
*
Yes
No
Reason for requesting shoe assistance
*
Family is experiencing financial hardship and unable to purchase shoes
Child needs appropriate shoes for school because they have no new shoes to wear to school
Acknowledgment and Follow-up Permission
SafeGround Shoe Assistance Acknowledgment
I have read and understand the statement above.
*
Yes
Submit
Should be Empty: