Children with Hair Loss - Hair Application

Recipient Full Name*

First NameLast Name
Parent or Contact Person Full Name*

First NameLast Name
Relationship to recipient
Recipient's Gender*

MaleFemale
Recipient's Birthdate*

MonthDayYear
Date
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 Diagnosis
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 measurements*
Please add any comments, concerns or special requests
DOCUMENTS UPLOAD

All applications for hair must include the following documents:
- Before and after hair loss photos
- Birth certificate or state identification
- Hair loss diagnosis letter from Doctor
Photos are not shared publicly. They simply help us choose the best hair replacement option for our applicant.

Please upload the following:
1. COLOR photo taken before hair loss
2. Current COLOR photo showing hair loss
3. Birth Certificate or State ID
4. Letter of medical necessity from Doctor stating hair loss diagnosis dated within the last 12 months
File Upload

Cancelof
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.
Should be Empty:

DOCUMENTS UPLOAD