My Happy Hair Nomination Form

Name *

First

Last

Address: (City, State, Zip) *

Birthdate (mm/dd/yyyy) *

Age *

Email *

Phone Number *

(This the recipient

Reason for hair loss (simple description of the diagnosis or condition causing hair loss) *

Is the intended recipient currently in treatment and if so, what kind? *

Has the intended recipient already lost all her hair, or anticipating the loss of her hair? *

Would the intended recipient be unable to afford a wig on her own? (This helps us understand her financial need and eligibility for a gifted wig. *