Apply for a Wig

We partnered with Children with Hair Loss™ (CWHL), a non-profit organization that provides free wigs to kids. If they don’t have any wigs, try your local ACS, or purchase a discounted wig from Andrew DiSimone Wigs™Please direct ALL questions to Children with Hair Loss.

Children With Hair Loss
12776 Dixie Hwy
South Rockwood, MI 48179
Tel: (734) 379 4400
Fax: (734) 379-8983
Email: info@childrenwithhairloss.us

How to Qualify for Hair Replacement

  • Be under the age of 21 (need proof of date of birth by attaching to the form below, fax (734) 379-8983 or mail. Example: Birth Certificate, Driver’s License or School Student I.D.).
  • Be experiencing hair loss due to a documented medical condition diagnosed by their physician.
  • Fill out the Online Request for Hair Replacement Form (below) or print the PDF Form, fill it out and send it to us, then we will contact you about your hair replacement needs.
  • Please submit application, birth certificate, doctor verification of diagnosis and a picture, if possible, with and with out hair so it can help us design the hair replacement. These pictures will not be shared and only CWHL will use them. When the package is delivered to the home, salon, or hospital, a signature will be required.

Application Form

All the information you submit via this form will be automatically sent to “Children With Hair Loss“.

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