Wig Recipient Application

Apply to Receive a Custom Wig

All fields marked * are required. Applicants must be medically diagnosed to qualify.

1. Personal Information Full Name *

Date of Birth *

Address *

Phone Number *

Email Address *

2. Medical Diagnosis Medical Condition *

If “Other,” please describe:

Date of Diagnosis *

Physician Name *

Physician Contact (phone or email) *

Upload Medical Certification (PDF, JPG) *

3. Wig Preferences Natural Hair Texture *

Desired Wig Color/Style *

Head Circumference (in/cm) *

4. Eligibility & Consent I confirm I am currently under medical care for the condition above.

I have not received a Foundation wig before.

I consent to having my photo and a personal letter shared in Foundation communications.

I have read and agree to the Program Terms & Conditions.

Signature (type full name) *

Date *

5. Additional Information Please share any other details that will help us serve you best: