Hairpiece Application

Please note: Locks of Love is a children’s charity and all of our recipients are under the age of 21.

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

How did you hear about us?

Referred By:

Required Documents to Include

Please note: if you are unable to upload any of these documents, please email them to casemanager@locksoflove.org so we may process your application.

Medical

Doctor's diagnosis

Length of Treatment if applicable

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

Financial

Parent/Guardian's most recent tax returns (1040 form)

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

Personal

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

Letter of Recommendation (1)

Letter of Recommendation (2)