Hair Application – Children With Hair Loss

CWHL provides a complete care kit along with a human hair replacement. We also provide support and education to our recipients and to our volunteer cosmetologists and barbers. Our services and products are provided free of charges to recipients annually until age 21.

How to Qualify for Hair Replacement

Be under the age of 21 (need proof of date of birth by attaching to the form below. Example: Birth Certificate, Driver’s License or School Student I.D.)
Be experiencing hair loss due to a documented medical condition diagnosed by their physician.
Fill out the Online Request for Hair Replacement Form (below) or print the PDF Form, fill it out and send it to us, then we will contact you about your hair replacement needs.
Please submit application, birth certificate, doctor verification of diagnosis and a picture, if possible, with and with out hair so it can help us design the hair replacement. These pictures will not be shared and only CWHL will use them. When the package is delivered to the home, salon, or hospital, a signature will be required.

If you have any questions about applying for Hair Replacement please give us a call or send us an email with your questions. We look forward to helping with your Hair Replacement.

IMPORTANT: Please be sure to CLICK HERE to watch the hair care videos before washing your hair replacement

Recipient's Full Name

Parent's Full Name

OR

Contact Person Full Name

Contact Person's Relationship

Gender

Birthdate

Mailing Address

City

State

Zip Code

Phone Number

E-mail

Hair Diagnosis

Referring Salon (if applicable)

Referred By

Salon Name

Street Address

City

State

Zip Code

Phone

E-mail

Hair Replacement Specifics

Hair Color

Head Measurement

What activities are you involved in?

Comments

Documents Upload

All applications for hair must include the following documents:

Before and after hair loss photos
Birth certificate or state identification
Hair loss diagnosis letter from Doctor

Photos are not shared publicly. They simply help us choose the best hair replacement option for our applicant.

COLOR photo taken before hair loss

Current COLOR photo showing hair loss

Birth Certificate or State ID

Letter of medical necessity from Doctor stating hair loss diagnosis dated within the last 12 months

*If you have difficulty submitting this form from your mobile device, please try from a desktop computer.

Click for PDF Form