WIG APPLICATION

We are here to help

Please note wig applications will not be reviewed unless all the required documents are submitted and all questions on the form are answered

You must be 18 years old or over to submit a wig application

Hair We Share gives a wig free of charge to children 18 years old and under with a medical hair loss condition. If over 18 years old, we offer a free wig based on financial need and approval.

Must be a U.S. resident
Anyone with permanent hair loss may apply once a year.
We respect your privacy, but we do ask that you help us with our fundraising efforts so we can continue to grow and help others.
We will reply by email within one week, please check your spam.
Please direct any questions, comments, or concerns to care@hairweshare.org

Required Documents for Children 18 years and younger:

Doctors Prescription

Required documents over 18 years of age

Doctors prescription
Proof of need for financial support

Acceptable documents to show proof of income status:

W-2 – Income Statement. This standard document provides proof of income the government uses to verify income for tax purposes.
1099 – Miscellaneous Income.
Federal Income Tax Return.
Social Security Statement.
If you have no income and have not filed taxes, you can request an “Income Transcript” from the IRS. An Income transcript is free when you request it by submitting form 4506-T, “Request for Transcript of Tax Return,” either online or by mail. The form is available on the IRS website (https://www.irs.gov/forms-pubs/about-form-4506-t)

The application approval process

Applications are determined on a case by case basis determined by our board of directors.
There is no single person in our organization who has the ability to approve or deny an application alone.
For applicants over 18 years of age we take into consideration cost of living in the area which you reside. We will also take into consideration cost of medical treatments you maybe undergoing (please provide this information and show receipts).
The “personal information” section will have no bearing on a decision for approval. This section is to help with our media efforts. It helps us to share stories of our recipients and grow our mission so we can help more people.
Applications will not be reviewed and contact will not be made by Hair We Share unless all required documents are provided.
If you do not have the documents readily available you can submit the application, and send documents to care@hairweshare.org .
Completed applications will be replied within 5 business days.

First Name *

Middle Name

Last Name *

Legal Gaurdian NameIf under 18, please state the name of the legal guardian

Email Address *

Phone Number

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Date of Birth *

Documents *

Doctors prescription stating reason for hair loss (If over 18 years of age, you must submit one of the following)Most recent tax returnsOther proof to verify financial statusPLEASE NOTE:These documents must be submitted before an application can be reviewed. Over 18 must include financial documents and prescription.

Required Documents

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Email required documents to Care@hairweshare.org or by clicking the upload file link here

Upload file Doctors Prescription

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Upload Photo

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My natural hair color is

About YouThis section is for our use to share stories of the people we help. We do not take any information in consideration when reveiwing applications. Please provide personal anecdotes (i.e. interests, hobbies, and other “colorful” attributes that help describe recipients’ situation, personality, perspective): Feel free to attach additional information.

I understand that I will receive no communication from Hair We Share until I submit the documents to support my application. *

Yes, I understand I will nor receive communicaion from Hair We Share until the required documents are submitted

Use of informationIt is helpful for us to grow and help others if we can use some or all of the information that you have provided in our media efforts. This is optional and we will always respect your privacy. If you prefer to remain anonymous we understand, we may still use part of your story without revealing any personal information about you.

Release *I hereby authorize and grant to Hair We Share Inc. (“HWS”), its licensees, assignees and all those acting with its authority or permission, or on its behalf, the irrevocable, unrestricted right to record, use, re-use, reproduce, display, copyright, stream, publish, or otherwise distribute any photograph, video, or digital content created about or including me solely with regard to being a HWS wig recipient without restriction whatsoever (“Participant”). Such right and permission includes, but is not limited to, my likeness, image, name, recorded voice or video, photograph, biographical information, or any material based upon or derived therefrom, for any and all purposes, in whole or in any part, relating to or arising out of being a Participant, in any form or medium, now or hereafter known or invented, including but not limited to promotion, advertising, and trade. I understand that HWS may, at its sole discretion, produce presentations or publications based in whole or in part upon my participation as a Participant, or any portions thereof, and/or video or audio recordings or photographs of said participation, and that such media may appear in print, online, or in any manner or media, including but not limited to promoting HWS. I further consent to having any such participation as Participant, or any portions thereof, and/or video or audio recordings or photographs of said participation altered or changed in any way for any purpose in connection with such uses. I hereby waive any and all rights that I may have to inspect or approve any finished product or any copy which may be used in connection herewith, or any use to which it may be applied. I understand that I have no claim for compensation and no claim, including, without limitation, claims based upon defamation, arising out of or in connection with any use, alteration, or use in any composite form hereunder. I also understand that HWS may, at its sole discretion, decide not to use, publish or distribute any or all of the portions of my participation as Participant. I hereby release HWS, together with all principals, officers, employees, agents, successors, heirs, and assigns and hold them harmless from any liability or claim arising out of or in connection with my participation as Participant. I hereby warrant and represent that I have the right to enter into this agreement and to grant the rights granted to HWS (or, if I am a minor under the age of 18 or an adult with a guardianship, my parent/guardian is warranting and representing such) for my Participant participation herein. This release shall be binding upon me and my heirs, legal representatives, and assigns.

Checkbox *

Recipient understands that wigs are provided on an “as is” basis and may not have been cleaned, modified or otherwise treated in accordance with any applicable laws or regulatory standards. Recipient understands and agrees that the use of the wig provided is solely at Recipient’s own risk, and Hair We Share Inc. will not be responsible for any harm or injury that Recipient may incur as a result of such use, including but not limited to, allergic reactions or sores caused by friction. Recipient agrees to release and hold harmless Hair We Share Inc., its licensees, assigns, representatives, directors, officers, employees and agents, from and against all claims, liabilities, damages, costs, and reasonable attorney’s fees arising out of or in connection with Recipient’s, its designees or assignees, use or misuse of the wig, whether by act or omission.Hold Harmless Release

Sign with your nameBy submitting this form I verify that I am the recipient or LEGAL PARENT or GUARDIAN of the Hair We Share recipient and understand the terms described to me. I authorize Hair We Share, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Hair We Share may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, and web content. I have included my NAME AND PHONE NUMBER for verification. My name and phone number are provided below for verification and will be considered as my electronic signature upon the submission of this form.

Date

GDPR *Yes, I agree with Privacy Policy, Terms and Condition

WIG APPLICATION

We are here to help

Documents *

I understand that I will receive no communication from Hair We Share until I submit the documents to support my application. *

Checkbox *

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