Section 1: Personal Details

Are you applying for yourself or for someone else?

Write Here *

* If on behalf of someone else, please fill in their personal information below and

state your relationship with them.

Full Name

Age

Full Name *

Age *

Address

Phone Number

Email *

Phone Number *

Contact information

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Country

Section 2: Your Story

If you feel comfortable, can you tell us about your diagnosis?

Write Here *

Please upload proof of your diagnosis.

Attachments *

Choose file or drag here

Supported format: JPG, JPEG, PNG, GIF, SVG.

temp-for-134415-file2-2_

Please share your hair loss journey with us.

Write Here *

How has this experience changed your day-to-day life?

Write Here *

Section 3: Emotional Impact

What has been the biggest impact of hair loss on your confidence or identity?

Write Here *

How would your friends and family describe you?

Write Here *

What message would you share with other women and girls experiencing hair loss?

Write Here *

Section 4: Your Dream Wig

What does your dream wig look like? Colour, length, style, etc...

Write Here *

Have you worn wigs before? If yes, what has your experience been like?

Write Here *

Who is your celebrity hair inspiration?

Write Here *

Section 5: Grant Impact

What would receiving this grant make you feel?

Write Here *

How do you think this wig would impact your life?

Write Here *

Is there anything else you’d like to share with us?

Write Here *

Section 6: Media Participation & Consent

As part of The Wigs for Women Grant, all recipients are required to allow The BHB to share part of their journey to help inspire and support other women and girls.

Do you agree to be featured on our social media platforms? *

Yes (Required)

Do you consent to photos and/or videos being taken and shared as part of your transformation and story? *

Yes (Required)

Section 7: Take A Snap

Please upload a picture and/or video of yourself below.

Attachments *

Choose file or drag here

Supported format: JPG, JPEG, PNG, MOV, MP4

temp-for-134415-file2-1_

How did you hear about The BHB? *

Please expand on your answer *

Your answers will be kept confidential by The Beautiful Hair Boutique and not shared publicly. Grant recipients are excluded. All answers submitted are final and cannot be changed. All information must be filled in and is required to be considered for the grant.

Your application to The Wigs for Women Grant has been received!

Thank you for sharing your story with us.

The Beautiful Hair Boutique will contact you by telephone or email using the contact information you submitted in the event of your successful application.

Your application to The Wigs for Women Grant has been received!

Thank you for sharing your story with us.

The Beautiful Hair Boutique will contact you by telephone or email using the contact information you submitted in the event of your successful application.

Wigs for Women Grant Application Form

Section 1: Personal Details

Are you applying for yourself or for someone else?

Full Name

Age

Address

Phone Number

Contact information

Section 2: Your Story

If you feel comfortable, can you tell us about your diagnosis?

Please upload proof of your diagnosis.

Please share your hair loss journey with us.

How has this experience changed your day-to-day life?

Section 3: Emotional Impact

What has been the biggest impact of hair loss on your confidence or identity?

How would your friends and family describe you?

What message would you share with other women and girls experiencing hair loss?

Section 4: Your Dream Wig

What does your dream wig look like? Colour, length, style, etc...

Have you worn wigs before? If yes, what has your experience been like?

Who is your celebrity hair inspiration?

Section 5: Grant Impact

What would receiving this grant make you feel?

How do you think this wig would impact your life?

Is there anything else you’d like to share with us?

Section 6: Media Participation & Consent

As part of The Wigs for Women Grant, all recipients are required to allow The BHB to share part of their journey to help inspire and support other women and girls.

Section 7: Take A Snap

Products

+ Colour

+ Length

+ Price

+ Availability (1)