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
(Please print clearly)
Name of Donor: _______________________________________________________________
Street Address: _____________________________________________ Apt/Suite: ________
City: _______________________________________ State: ________ Zip Code: __________
E-Mail: __________________________________________ Phone: _____________________
(Providing your e-mail saves the charity money on postage!)
*A certificate of appreciation will be mailed to you. Please allow 4-6 weeks to receive your certificate and/or t-shirt.
Have you donated to us in the past? _____ Any Comments?? ____________________________________
Did you include a picture? ___ Do we have permission to publish it? ___ Signature____________________
Find us on Facebook & Twitter 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.....please consider contributing a tax deductible donation today!
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
I HAVE ENCLOSED A $20 DONATION TO RECEIVE A T-SHIRT THAT READS:
“I DONATED MY HAIR TO CHILDREN WITH HAIR LOSS” (Please select size and color of t-shirt)
SIZE:
___Youth Medium (Fits up to child size 8)
Adult:
COLOR (Select one):
___Youth Large (Fits up to child size 14)
___SM ___MD ___LG ___XL ___XXL ___XXXL ___XXXXL
___Black Shirt w/ White Writing
___Pink Shirt w/ Black Writing
(YOU CAN SEE THE T-SHIRTS ON OUR WEBSITE)
www.childrenwithhairloss.us
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: ____________________________________________________