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. Color picture(s) of the applicant facing front and also back so we can see their natural hairline, hair color, hair length and hair texture. Please make sure the photos are in good lighting. If the applicant has already lost hair at the time of application, we will need those photos as well. We do not accept photos with filters or with the face scribbled out. These pictures are used for the sole purpose of recreating and replacing the hair of the applicant with a wig or topper that is best for their hair loss diagnosis, that closely matches their natural hair they've lost. We understand that not everyone is not comfortable sharing these photos. However, we cannot do our job successfully without them. These photos are never published. You may send up to 6 photos.

We rely on private donations, small grants, and fundraisers to sustain funding. Our supporters trust that we are gifting to kids with medical hair loss needs. Therefore we must enforce our hair application process in order to verify and provide properly for every child's medical hair loss need.

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.