Free Wig Application Form

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Fill out form in full to qualify for "Free Wig". (All information is confidential and secure.)

Please call 800-642-0345 with any questions.

This is a secure page. Your Inforamtion is held in full confidence.

Date of Application *

YYYY

Child's Full Name *

(First, Middle, Last)

Date of Birth *

Month/Day/Year

YYYY

Age *

Please choose gender *

Female

Male

Ethnicity *

African American

Arab American

Asian American

Hispanic American

American Indian

Caucasian

Other

Street Address and Apt.# *

City *

State *

Zip Code *

Home Phone Number *

Insert Numbers Only Including Area Code

Mother / Guardian's Full Name *

Mother / Father / Guardian's Address if Different than Above

Please add non-residential parents address if living seperately.

Mother / Father / Guardian's Cell Phone *

Insert Numbers Only Including Area Code

Mother / Father / Guardian's Work Phone

Insert Numbers Only Including Area Code

Parent's Email Address

Applicant's Email Address *

Alternate Contact Person (Alternate Emergency Contact Required) *

Name | Address | Phone | Email | Relationship to Applicant

Digital Signature of Parent or Guardian *

By typing in your initial's below you certify that you are the legal parent/guardian of this applicant.

Medical Information

Do you have a prescription for a cranial prosthesis (wig)? *

Yes

What is your medical diagnosis? *

If unknown, describe in your own best word's.

Are you currently undergoing medical treatment? *

Yes

If yes, what type of treatment?

Include treatment time duration as of the date of this application?

Have you already experienced hair loss? *

Yes

Name of Physician

Hospital / Office Address

Physician Phone Number

Insert Numbers Only Including Area Code

Referral Information

Name of Referring Organization / Hospital

Address of Referring Organization or Hospital

Phone Number of Referring Organization or Hospital

Contact Person at Referring Organization or Hospital

Title of Contact Person

Doctor

Nurse

Social Worker

Friend

Other

Clear selection

If we have any questions is it ok to call or email you? *

Yes

Thank You! Please allow 2-3 weeks for approval.

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