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.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Funding towards a Freedom WigFunding towards another brand of wigFunding to purchase Topper piece (for partial hair loss)Funding towards Mesh IntegrationFunding towards maintenance of wig/topper/mesh integration
How much have you been quoted for your piece/maintenance? (please note we may need a quote to be provided)
YesNo
How long have you been experiencing hair loss?*
YesNo
Previously received fundingI have never received Rapunzel Foundation funding before
Last 6-12 monthsLast 1-2 yearsLast 2-3 yearsMore than 3 years agoNever previously received funding/wig
What amount did you previously receive from The Rapunzel Foundation? *
Current application pendingWithin the last 6 monthsWithin the last 12 monthsOver 12 months agoI have never claimed the Treatment Benefit Scheme
YesNo
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
Are you also using the TBS or HSE grant towards the piece you are purchasing and if not why not? (not entitled, previously used etc)
Please provide us with as much information as possible regarding your 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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