Referral to Clothes to Kids of Fairfield County

Referral to Clothes To Kids of Fairfield County

Note to Referring Agency: To be valid this form must be dated, signed, filled out completely, and printed on the letterhead of the referring school, agency, or other approved advocate for the family. This layout may be modified as needed, but please do not delete any information.

Please fill in ALL student information. Clothes To Kids serves students attending Fairfield County schools, in grades K–12th and those working toward a GED. Children younger than 4 years old are not eligible to shop, even if they are in daycare or Headstart, and should not be included on this form.

Date of Referral Referral expires in 2 months from date

Parent/Guardian Name(s)

Mailing Address

City Zip Phone

Student(s):

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Name School D.O.B. Pant Size Shoe Size

Referred by:

I am familiar with the above family and their needs and would like to request clothing for the student(s).

Print name Signature

Title Phone Email

Note to Parents/Guardians: You must make an appointment to shop at the Clothes To Kids store. Contact Christine Santana (203) 548-0602 e-mail . Please bring this completed referral form and a photo ID to the appointment. If you cannot keep your appointment you must call to cancel.

Nota para padres / tutores:Debehacer una cita para comprar en la tienda Clothes To Kids. Póngase en contacto con Christine Santana (203) 548-0602 o por correo electrónico. Lleve este formulario de referencia completo y una identificación con foto a la cita. Si no puede cumplir con su cita, debe llamar para cancelarla

Address/Dirección: Yerwood Center, 90 Fairfield Avenue, Stamford CT 06902 clothestokidsfairfieldcounty.org