2026 Recipient Application - Powered by Keap

Recipient Application *

Only a child's legal Representative can register an application for the program.

** If you have been active with Wigs For Kids in the past, STOP and call our office before completing this application. 440.333.4433 **

*If the child's Representative cannot complete the application for any reason including a language barrier, STOP and call our office. 440.333.4433 option 5

Section One:

Representative Information

Applicant Representative's Name *

Applicant Representative's Email *

Representative's Residency Address *

Apartment Or Suite Number

City *

State (XX) *

Postal Code *

Country *

United StatesCanada

Applicant Information

Applicant's First Name *

Applicant's Last Name *

Gender *

MaleFemale

Age *

Date of Birth (xx-xx-xxxx) *

Has the applicant received a hair replacement system from Wigs For Kids in the past? *

YesNo

How did you hear about Wigs For Kids? *

Applicant Representative's Phone Number (xxx)xxx-xxxx *

Preferred Contact Method Text Message.

By checking this box you agree to receive text message communication from Wigs for Kids to schedule initial appointment and follow up on the status of your hairpiece. Message frequency varies. Message and data rates may apply.

Preferred Contact Method Phone Call

Preferred Contact Method Email

Social Worker Information (If Applicable)

Social Worker Name (If Applicable)

Social Worker Email Address (If Applicable)

Social Worker Phone Number (If Applicable)

Section Two: Reason For Hair Loss

Type of hair loss *

AlopeciaBurnsChemotherapy/ Radiation Therapy/ Cancer Treatments TrichotillomaniaOther Cause of Hair Loss

If Other Type of Hair Loss Please Define

Check this box to agree to receive emails from Wigs For Kids *