Children with Hair Loss - Hair Application

Recipient Full Name*

First NameLast Name

Parent or Guardian Full Name*

First NameLast Name

Relationship to Recipient*

Recipient's Gender*

MaleFemale

Recipient's Birthdate*

Date

Recipient Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Hair Loss Diagnosis*

Hair Loss Diagnosis Date*

Date

Hospital Name

Doctor's Name

Doctor's Phone

Please enter a valid phone number.

Social Worker's Name

Social Worker's Phone

Please enter a valid phone number.

Social Worker's Email

example@example.com

Referring Salon Information (if applicable)

Salon/Barber Shop Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

Please enter a valid phone number.

Email

example@example.com

Have you received a hair replacement from Children With Hair Loss in the past? **

YesNo

HAIR REPLACEMENT SPECIFICS

Head Circumference Measurement*

Please add any comments, concerns or special requests

DOCUMENTS UPLOAD

All applications for hair must include the following documents:

1. Birth certificate, drivers license, or state identification of applicant
2. Birth certificate, drivers license, or state identification of parent/guardian
3. A letter from the doctor must be on their letterhead, signed, dated, and include the applicant's name, birthdate, hair loss diagnosis, and the date last seen by the doctor.
4. Before hair loss photos and current photos showing hair loss are required. These photos are used to help choose a wig or hairpiece that closely matches the hair that was lost and/or the best fit for the type of hair loss diagnosis. Please make sure the photos are in good lighting. You may send up to 6 photos. These photos are never published.

File Upload

IMPORTANT: The recipient and anyone helping to care for the human hair replacement has watched the Hair Care videos on this website*

YesNo

Please go back and refer to the hair care videos. Click here.