Shopping with Carter's House
Form Description
Email address *
Who were you referred by? *
Your answer
What is the date of your shopping appointment? *
MM
/
DD
/
YYYY
What time is your appointment scheduled? You need to visit bit.ly/requestappt to schedule your appointment. You DO NOT have an appointment until you complete this step. *
Time
:
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
What is your phone number? *
Your answer
Are you a grandparent raising your grandchildren? *
Street Address? *
Your answer
City? *
Your answer
Zip Code? *
Your answer
Are your children eligible for free/reduced lunch? *
Are you and your children homeless? *
If your answer is no, where do you live? *
Is anyone in the household a Veteran? *
If yes, please indicate where you served. *
What is your ethnicity? *
Child 1: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend? *
Your answer
Child 2: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend?
Your answer
Child 3: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend?
Your answer
Child 4: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend?
Your answer
Child 5: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend?
Your answer
Child 6: Please indicate the Name/ Age/ Gender/ Sizes (top, bottom and shoe) and what school they attend?
Your answer
If any of the above requests are for school uniforms, please indicate acceptable shirt/pants colors for each child.
Your answer
I hereby certify that all of the information that I have provided is true and accurate to the best of my knowledge. I understand that intentional falsification of any information on this application will result in denial of services. *
Submit
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