Partial Headband Wig Box Form
Please fill in ALL fields and submit this form to complete your request. Incomplete forms will not be reviewed. Each recipient that is chosen will be notified in the order received.
Partial Headband Wig Recipient's Full Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date
Contact Number (the recipient will be contacted)
*
Format: (000) 000-0000.
E-mail (you will be contacted from contact@crownedqueen.org)
*
example@example.com
Shipping/Drop-off Address of the Recipient (the box will be sent to this address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you find out about Crowned Queen?
*
Google
Facebook
Instagram
Business Card
Previous recipient/word of mouth
Recommended by a Board Member
If your answer was previous recipient, word of mouth, or board member, please let us know who recommended you?
*
Do you have a medical condition that has caused you to experience hair loss?
*
What is your diagnosis/medical condition that has caused hair loss? (this information is confidential and will not be shared with any outside sources)
*
How long have you had this health condition that has caused you to experience hair loss?
*
Are you currently under doctor(s) care for your medical condition?
*
Yes
No
On a scale of 1-4, how has your mental health been affected due to your medical condition?
*
1- not at all
2- somewhat
3- I have my days
4- it has definitely affected my mental
Share more of your story here. We would love to learn more about you:
*
How would you explain your hair length?
*
my hair is short (under 1 inch)
my hair is afro length (a few inches)
my hair is shoulder length
my hair is pass shoulder length
We offer turbans, headwraps, and Braid/Loc Partial Headband Wigs to our recipients. Please answer the questions below.
Would you like to have a Braid or Loc Partial Headband Wig?
*
Braids
Locs
I would prefer to have more turbans instead of the Partial Headband Wig
What length would you like for your Partial Headband Wig?
10”
12”
14”
What color and hair type would you like for your Partial Headband Wig?
1B with curly hair
1B (NO curly hair)
Grey and 1B with curly hair
Grey and 1B (NO curly hair)
Turban Options (choose 3 and you will receive the 2 that are available)
*
prev
next
( X )
Big Braid Turban
Free
$
Free
Color
Black
Navy
Brown
Royal Blue
Braided Turban
Free
$
Free
Color
Black
Royal Blue
Heather Grey
Khaki
Mustard
Wine
Purple
Double Twisted Turban
Free
$
Free
Color
Black
Navy
Khaki
Grey
Royal
Wine
I grant permission to Crowned Queen the rights of my image, in video or still, and of the likeness and sound of my voice as recorded on audio or video tape with no payment. I, as the Releasor, understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio and/or video recordings may be used for the following purposes: courses and educational materials, Films (movie), Media, News (Press), Online/Internet Videos and/or Photographs, Presentations, Websites, Social Media Platforms (posts, stories, reels) including groups, personal, and business pages, Emails and Text Message Communications, Other. I understand this permission signifies that photographic or video recordings of me may be electronically displayed via internet or in the public educational setting. I will be consulted about the use of photographs or video recording for any purpose other than those listed above.The validity of this Consent is;For an unlimited time. This release applies to all photographic, audio or video recordings collected of me during any event, photoshoot, and/or interview pertaining to Crowned Queen or in collaboration with Crowned Queen. By agreeing to this release, I acknowledge that I completely read and understand the above release and agree to be bound by its terms. I hereby release any and all claims against any person or organization utilizing this material for the purposes stated above.
*
yes, I agree with the above statement
no, I do not agree with the above statement
Signature
*
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