Project Shoes Referral/Request Form
This form should be completed for any and all Project Shoes Referrals/Requests beginning May 16, 2020. If you have questions pertaining to Project Shoes, please email bjwcprojectshoes@gmail.com and cc bjwclub@gmail.com.

*Note: Please complete a separate form for each child.

Thank you for your continued use of this program!
Date of Referral: *
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Name of Referring Party/School Social Worker: *
Your answer
Referring Party's Agency/School: *
Your answer
Referring Party's Telephone Number: *
Your answer
Referring Party's Email Address: *
Your answer
What school does the child attend? *
Your answer
What grade is the child in?
Your answer
What size shoe does the child wear? Is this a child or adult size shoe? *
Your answer
What is the child's age? *
Your answer
What is the child's gender? *
Are there any special instructions pertaining to this referral? (Example: type of shoe needed, color, occasion)
Your answer
What date are the shoes needed by? *
MM
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DD
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YYYY
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