Shoe Vouchers

Child's First Initial *

Child's Last Initial *

Child's Medicaid ID Number (#######A) *

The Medicaid ID number is seven digits followed by a letter. Please provide the correct format or your application will NOT be processed.

Child's Age *

Effective July 1, 2022, Shoe Vouchers are limited to children ages 4 to 18.

Child's Gender *

Child's Status *

Please note: Children who have been adopted from foster care do NOT qualify for this program.

Your Caregiver Role *

Caregiver Name *

First

Last

Caregiver Phone Number *

Caregiver Email Address *

Yes, I have verified my address to ensure its accuracy for the mailing of the Shoe Voucher to my residence. *

Yes
No

Yes, I understand, that failure to comply with the expiration date, will result in the loss of my Shoe Voucher. *

Yes
No

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Caregiver County *

Caseworker Name *

First

Last

Email of CASE WORKER, please do not provide your email address, the application will not be processed. *

Please provide your CASE WORKER’S EMAIL ADDRESS, applications without caseworker’s emailed, will not be processed.

I acknowledge that I have read and agree to all program requirements and that the information I have provided is truthful. I understand that falsifying any information will result in loss of eligibility for all FHF programs and services. *

Yes
No

I acknowledge that the Shoe Voucher I am requesting has an expiration date and must be redeemed prior to the expiration date listed on the voucher. Shoe Vouchers will not be re-issued if the expiration date passes. *

Yes
No

Yes, I understand, if I go over my allotted amount given for my Shoe Voucher, I am to pay to difference for the pair of shoes in cash. *

Yes
No

Yes I understand, that Shoe Vouchers can take 1-3 weeks for processing and approval. *

Yes
No

Caregiver Signature *

Date of Application *

Who qualifies for the Shoe Voucher Program?

How does the Shoe Voucher work?

Sports & Activity Footwear

Apply Here