Angel Hair Foundation Application

Angel Hair Foundation

PO Box 2727, Eugene, OR 97402 | jeannine@angelhairfoundation.org | 541-915-8683 www.angelhairfoundation.org
PRIMARY INFORMATION
Child Last Name*
Child First Name*
Mailing Address*
City*
State*
Zip*
Phone*
Email*
Birth Date (MM/DD/YEAR)*

MonthDayYear
Gender
Parent/Guardian Name*
Relationship To Applicant*
MEDICAL INFORMATION
What is your medical diagnosis or condition?*
What is your diagnostic code?
Are you currently undergoing medical treatment?*

YesNo
If yes, what kind of treatment? (Chemotherapy, radiation therapy, etc.)
Have you already experienced hair loss?

YesNo
Name of your physician*
Hospital or medical center of treatment
FEEDBACK
How did you hear about Angel Hair Foundation’s services?
I authorize the release of any medical or other information necessary to process an insurance claim. I also request payment of government benefits either to myself or to Angel Hair Foundation.
Signature*

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Date*

MonthDayYear
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