AMF 2016 Grant Application

Medi Hair Loss Clinic Community Giving Application

Cycle 2 Deadline: October 12, 2025 at 5:00 pm
At Medi Hair Loss & Scalp Clinic, we are deeply committed to supporting individuals affected by alopecia and other hair loss conditions in the communities we serve. Our Giving Program is designed to empower communities by providing financial support to nonprofit organizations that align with our mission of promoting hair and scalp health, wellness, and confidence.

Each year, we provide funding to organizations that:
✅ Support individuals experiencing alopecia, hair loss, or scalp disorders
✅ Offer wigs, hair prosthetics, or confidence-boosting programs for those with medical hair loss
✅ Provide mental health and wellness support for individuals dealing with self-image concerns due to hair loss
✅ Advocate for awareness, education, and research in the field of hair and scalp health

Members of Community Giving committee are glad to answer any questions about eligibility. Please email us at info@medihairlossclinic.com.

Note: Please review all of the application questions below and required documents that need to be included. For longer answers you may want to copy and paste text from another document into this form. There are no word count limits for the narrative questions, but please try to limit responses to no more than 200 words.

If you need any assistance with this online application or have any questions, please contact Medi Hair Loss Clinic at info@medihairlossclinic.com
Eligibility
Please select the category that best describes your request:*

An individual requestA group or individual seeking pledgesA political organizationNone of the above
I acknowledge that the Medi Hair Loss Clinic Giving Program does not fund event sponsorships. My request is for financial support for an ongoing program or general operational funding, not related to an event*

YesNo
Does your organization ensure equal access to services for all individuals, without discrimination based on age, race, ethnicity, national origin, sexual orientation, religion, abilities, marital or parental status, military or veteran status, or any other legally protected status?*

YesNo
Organization Information
Organization Name:*
Please enter the name of your organization as it appears on all legal documents, such as its IRS determination letter, articles of incorporation and/or bylaws.
Your Canadian Government issued non-profit registration number.*
Doing Business As (DBA) Name:*
If your organization operates under / goes by something other than its legal name, please enter it below.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail:*
Alternate E-mail:
Website:
Phone Number:*

Area CodePhone Number
Alternate/Cell Phone Number:

Area CodePhone Number
Executive Director:*
Primary Contact (if different from above):
Organization Type:*

Nonprofit OrganizationUnincorporated, Using Fiscal Sponsor
Year Founded:*
Describes your organization's primary mission*
Describe the service(s) your organization provides.*
What geographical area does your program serve?*
Estimated number of people served annually.*
Have you received funding from Medi Hair Loss Clinic within the last three (3) years?*

YesNo
Would you like Medi Hair Loss Clinic staff to volunteer at your organization?*

YesNo
What type of support are you requesting?*

General Operating SupportSpecific Programs
How will the funding from Medi Hair Loss Clinic be used to support and benefit people?*
Contact Infomation
Primary Proposal Contact Full Name*

First NameLast Name
Primary Proposal Contact Job Title
Primary Proposal Contact Phone Number*

Area CodePhone Number
Primary Proposal Contact Email Address*
example@example.com
Is the Primary contact also the organization's financial contact?*

YesNo
Were you referred by Medi Hair Loss Clinic Staff?*

YesNo
What is the CDN dollar amount you are requesting?*

100 – 500500 – 1000
Agreements
Please acknowledge that you have read the Donation Terms and Conditions (“https://medihairlossclinic.com/community-giving-agreement") and you have the authority to enter into and agree on behalf of the organization to be bound by the Agreement*

YesNo
Should be Empty:

Medi Hair Loss Clinic Community Giving Application

Eligibility

Organization Information

Contact Infomation

Agreements