Hairpiece Application

Child's Information

First Name

Last Name

Middle Initial

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Gender

Ethnicity

Parent/Guardian's Information

First Name

Last Name

Relationship

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email

How did you hear about us?

Referred By:

Required Documents to Include

Medical

Doctor's diagnosis

Photo of child without hairpiece or hat to help us with the custom fit

Financial

Parent/Guardian's most recent tax returns

or

Other proof of income: Social Secutity, Welfare, Disability Income

Personal

Two letters of recommendation from a paarent, teacher, friend, coach, etc. explaining why the child would benefit from a hairpiece.

Letter of Recommendation (1)

Letter of Recommendation (2)