Children with Hair Loss Testimonials

Name*

First NameLast Name
Child's First Name and Last Initial
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*
City*
Country*
US States (select last option if you live in a country other than the US)*
Zip or Postal Code *
Are you (or your child) a CWHL recipient?*

YesNo
Your Testimonial *
Photos

If you have photos, please submit up to 3. If you encounter difficulty due to file size, please try submitting fewer images.
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Please Select The Permission You Give To Children With Hair Loss To Use Your Testimonial

We will never publish the last name in a testimonial. Please understand that submitting a testimonial does not necessarily mean it will be used on the Children With Hair Loss website or in print materials.
Please select the permission you would like to give to CWHL*

CWHL may use the photo(s) and written testimonial on the website and/or in print materialCWHL may use the written testimonial only on the website and/or in print materialCWHL may NOT use this testimonial and/or picture(s) on the website and/or in print material
Please rate your experience with Children With Hair Loss*
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Please Select The Permission You Give To Children With Hair Loss To Use Your Testimonial