Shoe Request Form

Requests for asssitance may be made only by pre-registered schools, charities, shelters and agencies. If you represent a school, charity, shelter or social service agency and would like information on how to register, please email info@injacobsshoes.org or call (954) 905-2505.

 

Your Name - Teacher, Social Worker, Case Worker, etc. (required)

Agency Name (required)

Is Agency pre-registered with In Jacob's Shoes?

Your Email (required)

Your Telephone (required)

Agency's Telephone (required)

Agency's Website (required)

Agency's Address (required)

Please explain the reason for this request (required)

Youth's City of Residence (required)

Youth's County of Residence (required)

Youth's School Name and City (required)

Date items are needed

To assist us in selecting the appropriate shoe or backpack, please provide the following information:

Youth's Age (required)

Youth's Gender (required)

Youth's Shoe Size

You may select up to two shoe styles for each youth (subject to availability):

Select Shoe #1 Style

Select Shoe #2 Style

Does the youth need a backpack? (subject to availability)

Please provide any additional information here