Submit for Footwear Fund

Name of person with SB *

First Name

Last Name

Birthday Shout Out *

We are doing social media birthday announcements for our members with spina bifida that includes a photo and brief bio (first name, age, city of residence, hobbies and interests). We will email you prior to the month of your birthday to collect this information.

Yes, please email me for a birthday shout out and I give SBWIS permission to use the photo and information I provide on social media to acknowledge this birthday.

No thank you.

Name of person to make check out to *

Parent or Legal Guardian, trust fund account or vendor/bank. All checks will be mailed to your home address.

First Name

Last Name

Home mailing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Checkbox *

I understand my request is not complete until I email my receipt / proof of purchase to sbwis@sbwis.org (receipt showing payment).

I understand that I can submit more than one request to be reimbursed up to $50 per calendar year.

When I email my receipt / proof of purchase I will include a photo of the footwear I'm requesting reimbursement for purchasing. I give SBWIS permission to use this photo on social media with my first name to promote this service to our followers.

How do you keep in touch with SBWIS? *

Checking the website

Following Facebook posts

Newsletter postcard

Email blasts