Referral Form

Prom Wishes, Inc. PO Box 163 Sperry, OK 74073 [email protected] 918-288-6227

REFERRAL FORM Students Name: Address: State: ______Zip: ______School: Grade: ______Date of Prom: ______Location of Prom:

Referred By: Title: ______Address: State: ______Zip: ______School: Phone:

I certify that ______is a student in need of a prom dress and is enrolled in ______School as a student. I understand that Prom Wishes, Inc. will make every effort to outfit this student for their prom but cannot guarantee that they will have their dress size or services they need. These services are for High School students only and are on a first come first serve basis. Signed: ______Date: ______

Prom Dresses are located at First Baptist Church in Sperry, OK at 3rd and Main. They must call Sarah Bridgeman at 918 288-6227 for a private appointment. No dresses are given without an appointment. Student’s scheduled time to choose a dress and accessories is ______. If for some reason she is unable to make this appointment date and time, please contact Sarah Bridgeman at 918-288-6227 so we can reschedule.

RULES  Dresses are given on a first come, first serve basis.  Each girl will receive one dress and accessories, if available.  Each girl may bring one guest (parent/adult) to help her shop.  Each girl will need to bring a valid student I.D.  An information card will need to be filled out prior to choosing a dress.  Girls will be assisted in the dress selection process by volunteers who have signed confidentiality agreements.  Adults cannot shop in place of the girl unless there is a physical disability preventing her from doing so.  Appointments are Wed. between 3 and 5 p.m. unless special arrangements have been made.

Directions from Tulsa to FBC Sperry, 918 288-7711 (about 20 min. N. of Tulsa) Take Hwy. 75 N. to 86th St. Exit. Turn W. and drive about 4 miles to the first stop sign. Turn N. (R) onto Hwy. 11. After passing a park you will come to a Y, stay Left. (If you pass a gas station, you went too far.) As soon as you get to the next stop sign, turn N. (R) then you will come to another stop sign immediately, make a L and drive about 3 blocks and you will see the church on the Right. Park in the back parking lot and enter from the door on the North side of the church. (If unable to reach one of the above numbers you may try Cheri at 918 288-6899) Color of Clothes you are wearing today in order to identify you in pictures: Top: ______Bottom: ______I consent to being photographed for this project. These become the property of the Prom Wishes, Inc. and may be used to promote this project via television, newspaper and internet. I do not hold Prom Wishes, inc. responsible for any use of these pictures. Signed: ______Date: ______Foster Child Yes ______or No ______If yes, please complete the next 3 questions. Foster Parent: ______Case Worker: ______Case Worker Phone #: ______If this child is a foster child please indicate whether this child’s photos can or cannot be used for promoting Prom Wishes, Inc. Yes ______or No ______Pictures are taken only for proof that we have supplied a dress in case of any type of legal situation. Pictures taken of anyone who wishes them not to be used will remain on the camera/thumb drive for those purposes only.

Items Chosen: Dress/Color/Size: ______Shoes/Color/Size: ______Corsage: ______Jewelry: ______Purse/color:______Other Supplies: ______Gift Certificates: ______