Hair Donation Form - Children with Hair Loss

I HAVE ENCLOSED A $ DONATION TO HELP PAY FOR A CHILD’S HAIR REPLACEMENT
I HAVE ENCLOSED A $7 DONATION TO PAY FOR A HAT TO BE GIVEN TO A RECIPIENT OF CWHL
HAIR DONATION
Hair must be a minimum of 8 inches, clean, DRY, and in a ponytail OR braid.
Place your hair donation into a zip lock bag and then in any mailing envelope.
Please send this completed form along with your hair donation to:
Children With Hair Loss
12776 Dixie Hwy
S. Rockwood, MI 48179
(Print Clearly)
Name of Donor:
Email: Phone:
Please provide your Email allowing us to send your certificate faster, save money and help more kids • International donors receive certificate by Email
Street Address: Apt/Suite:
City:
State/Province/Region: Zip/Postal Code: Country:
Please print my certificate In Memory/Honor Of:
*A certificate of appreciation will be e-mailed or mailed to you. Please allow up to 6 weeks to receive your certificate and t-shirt.
Have you donated to us in the past? Any Comments??
Did you include a picture? Do we have your permission to publish it? Signature:
Find us on Facebook Facebook.com/CWHLMI & Twitter Twitter.com/cwhl_org and send us a photo and/or comment!!!
We appreciate your HAIR DONATION, but there is still a HUGE COST to have a hair replacement made.
Could you please consider contributing a tax deductible donation TODAY?
I HAVE ENCLOSED A $20 DONATION TO RECEIVE A T-SHIRT (Please select size and color of t-shirt)
SIZE: Youth Medium (Fits up to child size 8) Youth Large (Fits up to childe size 14)
Adult: SM MD LG XL XXL XXXL XXXXL
COLOR (Select One) Black Shirt w/White Writing Pink Shirt w/Black Writing
(YOU CAN SEE THE T-SHIRTS ON OUR WEBSITE)
*If you live outside the United States your order must be placed through our website
www.ChildrenWithHairLoss.us
Checks may be made payable to: Children With Hair Loss
To have your donation charged to your credit card, please fill in your information below:
Payment Type: Visa Master Card Discover American Express
Credit Card Number: Exp Date:
Name as it appears on card: 3 Digit Code on Back:
Signature of Cardholder:
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