Client Application Form

Client Application Form
***PLEASE NOTE: Due to the bylaws that govern our organization,
Maggie's Wigs 4 Kids of Michigan is only able to service Michigan children in need.***

To be eligible for Maggie's Wigs 4 Kids of Michigan program, please complete this form. As a wig recipient, you are an Ambassador of the program, and we request the following:

-A prescription from your physician for a wig
-Write a thank you letter to your wig sponsor in our Adopt-a-Kid program
-Before and after photos
-Complete pre, post and satisfaction surveys so we can best meet your needs
-If you know of a child in need of our services, please let them know about our program
-Participate (when health permits) in fundraising events
Your participation ensures this organization will be in existence for future children.
Date of Application
Client Name*

First Name Middle Name Last Name
Date of Birth

MonthDay Year
Date
Age
Gender

FemaleMale
Ethnicity

African AmericanArab AmericanAsian AmericanCaucasianHispanic American
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mother/Guardian's Full Name

First Name Last Name
Mother's Cell Phone

Area Code Phone Number
Mother's Work Phone

Area Code Phone Number
Father/Guardian's Full Name

First Name Last Name
Father's Cell Phone

Area Code Phone Number
Father's Work Phone

Area Code Phone Number
Family Email Address*
example@example.com
Alternate Contact

First Name Last Name
Relationship to Client
Alternate Contact Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Alternate Contact Phone Number

Area Code Phone Number
Parent/Guardian E-Signature

Clear

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