2000 Feet, Inc. Application for Shoes4KIDS

PART 1
How to Apply
  • Do not make copies of this application. Application must be submitted Online.

  • Answer ALL questions. Read the agreement. Check the “Agreement Acceptance”. Click only once to submit.
     Incomplete applications will delay processing.  
For FAQs : Frequently Asked Questions - Click Here.
Have your child(ren) received benefits from 2000 Feet, Inc. THIS year?
Yes. You do not qualify for benefits this year. Please apply next year.
NO. Please proceed and fully complete this application.
Check the reason for your request. YOU MUST BRING PROOF of YOUR GOVERNMENT BENEFITS for each child or PROOF OF YOUR HARDSHIP WITH YOU AND YOUR CHILD(REN) TO THE SHOPPING EVENT or click here to email documents.
My/This family is experiencing a Hardship/crisis, e.g., unemployment, natural disaster, etc.
My/This family is currently receiving Food Stamps, TANF, Gov’t Assisted Health Care

PART 2
Parent or Guardian Information
First Name:
Last Name:
Street Address:
City:
State: ZIP Code:
Phone Number:
Provide the best number for us to reach you.
E-Mail Address:
Is your Email address correct?
Number of parents in the household:
Number of children in the household:
Your Ethnicity/Race:

This information is collected to make sure everyone is treated fairly.
Your answer is voluntary, and does not affect your eligibility or benefit amount.

PART 3
If are referring this family and you are a LCSW, MSW, Nurse, Teacher, Professional Counselor, etc., complete this section and provide a reason for request in the Statements, Questions or Comments Box.
First Name:
Last Name:
Title:
City:
State: ZIP Code:
Agency:
Email a copy of your business card
E-Mail Address:
Is your Email address correct?

PART 4
List all information for each child age 5 to 15 years old only (Do NOT list children under or above this age range)
Child's First Name
Child's Last Name
Age
Date of Birth
(mm/dd/yyyy)
Gender
Ethnicity/Race
Last 4 Numbers on
Social Security Card
1.
M or F
2.
M or F
3.
M or F

PART 5
Check which event you plan to attend (You may only attend one event per calendar year)
Event Details, Click Here>>>

Saturday, February 25, 2010 (1:00pm - 2:00pm)
Payless Shoes 1003 W. Gannon Dr., Festus, MO


PART 6
Statements, Questions or Comments


PART 7
Agreement and Signature

By submitting this application, I waive and release any and all rights and claims for 2000 Feet, Inc., and its personnel, committees, volunteers and sponsors for any injury suffered by my child(ren) or myself at said event. If photos, videos or recordings are taken of my children or me, I give permission for 2000 Feet, Inc. and its affiliates to use any photographs, videotapes or other recordings of my children to be used in a promotional or marketing capacity for 2000 Feet, Inc.

I understand that if any information or document provided proves to be false or misleading, I and my children will be disqualified and cannot participate in any 2000 Feet, Inc., programs.
ALL NO-SHOWS WILL FORFEIT FUTURE BENEFITS.
I AGREE to the above terms and conditions. (Checking this box serves as your digital signature.)




2000 Feet, Inc. | PO Box 50114 | St. Louis, MO 63105 | 636.447.6362 | shoes4KIDS@2000FEET.org