Application for Full or Partial Funding

Application for Full or Partial Funding

All information provided will be kept confidential.
Name of person completing form*

First NameLast Name
Name of person application is for, if different from above

First NameLast Name
Date of Birth (of person in need of funding/wig)*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you seeking?*

A Freedom wig provided by RapunzelFull funding towards another brand of wigPartial funding towards a Freedom WigPartial funding towards another brand of wigFunding to purchase Topper piece (for partial hair loss)
How much have you been quoted if you're seeking funding for another brand of wig?
Do you have a medical condition that has caused hair loss?*

YesNo
Are you currently undergoing any medical treatment related to your hair loss?*

YesNo
How long have you been experiencing hair loss?*
Have you previously worn a wig?*

YesNo
Have you previously received funding from The Rapunzel Foundation*

Previously received a Freedom WigPreviously received partial funding towards a Freedom WigPreviously received full funding towards another wig brand or topper piecePreviously received partial funding towards another wig brand or topper pieceI have never received Rapunzel Foundation funding before
When did you last receive funding from The Rapunzel Foundation*

Last 6-12 monthsLast 1-2 yearsLast 2-3 yearsMore than 3 years agoNever previously received funding/wig
What did you previously receive from The Rapunzel Foundation? please type full funding or the amount and towards what type of piece. EG full funding towards a Freedom Wig/ €.... towards any wig brand *
When have you last claimed the Treatment Benefit Scheme (based on PRSI) towards a wig?*

Current application pendingWithin the last 6 monthsWithin the last 12 monthsOver 12 months agoI have never claimed the Treatment Benefit Scheme
Do you currently have a medical card?*

YesNo
Have you claimed the HSE Grant towards a wig previously?*

I am not entitled to the HSE grantI am entitled to the HSE grant but have not claimed it within the last 12 monthsI have not claimed the HSE grant within the last 12 month
Please provide us with as much information as possible regarding your condition and need for funding. We always have limited funding available, so the more information you can provide us, the better we can assess your application and need. *
Funding is allocated to applicants as it becomes available to us so the length of time you wait after applying can vary and you may be waiting up to 8 weeks to hear from us.

Our number one priority is always to get funding to those in need as soon as possible
Declaration: I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that providing false information may result in my application being rejected.*

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