Shoe & Hoodie Registration

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Shoe & Hoodie Registration - 2021

Please fill out this form to be eligible for the shoe & hoodie program through Communities In Schools of Southwest Virginia (CIS of SWVA). You will need to fill out a separate form for every student in your household. Please note, if you did not receive a letter from your student's school or from CIS of SWVA, do not fill out this form. Please call Aimee Rasnick at 276-644-9446 with any questions, thanks!

Email *

Student's Name *

Student's Age *

Student's School *

Student's Grade *

Parent/Guardian Name *

Street Address *

City, State, Zip *

Phone # *

Please select one of the following responses. *

I will be able to bring my child to Shoe Carnival to pick-up the shoes & hoodie.

I will be unable to bring my child to Shoe Carnival and would like the shoes & hoodie delivered to my student's school or our home if my student is a remote learner.

Please select which department your student typically shops for shoes. *

Girl's

Women's

Boy's

Men's

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