Application

Eligibility Requirements

-Must be 18 years old or younger
-Must be treated for medical hair loss in Illinois

-Referral letter from your treating doctor

Download Doctor's Referral Letter

Important Notice: If selected, funds will be sent directly to business where wig is being purchased.

To apply for financial assistance, you can:
(1) Complete electronic form. **No download necessary. Form is provided below.**
Note: You will not be able to save any work in progress.

(2) Print and send in a completed paper copy.
Note: Please make sure to read all instructions to prevent delays in your application process.

Download Application Form

Electronic Application Form