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Name (Yours, not your child's)*

Your email address*

Please re-enter your email address*

Your phone number*

Preferred Day:*

Monday - State a date and time (from 9:30 - 3:00) in next field)
Wednesday - State a date and time (from 9:30 - 3:00) in next field)
Friday - State a date and time (from 9:30 - 4:00) in next field)
Saturday - State a date and time (from 9:30 - 4:00) in next field)

Preferred Date:*

Preferred Time (check the opening times please):*

Number of children, their names & ages*

Current shoe size/ sizes*

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Details of what you expect you will need (tick all relevant boxes or enter details in "Other" box):*

School Shoes:

Leather school shoes BLACK
Leather school shoes NAVY
Black trainers (INSTEAD of leather school shoes)

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Trainers (P.E. or casual):

P.E. Black
P.E.White
Casual any colour

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Other:

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Expected total number of pairs*

Does your child/children wear orthotics?*

Yes
No

Any other relevant information

STOP!

All done? Great!

You may now submit your request. If a confirmation message does NOT appear on the screen there is something wrong - please check & submit again!

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