Apply – Custom Wigs

Sponsorship Nomination Form

Please fill out the following form if you know a child or teenager in need of support for issues of medical hair loss.

Child's Information

First Name

Last Name

Middle Initial

Address Line 1

Address Line 2

City

State

ZIP

Date of Birth

Gender

Ethnicity

Parent/Guardian's Information

First Name

Last Name

Relationship

Address Line 1

Address Line 2

City

State

ZIP Code

Home Phone

Work Phone

Cell Phone

Email

How did you hear about us?

Reffered By

Required Documents to Include

Medical

Doctor's diagnosis

Photo of child without hairpiece or hat to help us with the custom fit

Financial

Parent/Guardian's most recent tax returns

Or other proof of income: Social Secutity, Welfare, Disability Income

Personal

Two letters of recommendation from a paarent, teacher, friend, coach, etc. explaining why the child would benefit from a hairpiece.

Letter of Recommendation (1)

Letter of Recommendation (2)

CustomWigWorld4Kids is a nonprofit providing custom wigs for children, restoring confidence and hope during medical hair loss.

Quick Links

Quick Links

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