Hair Donation Form

Your hair can restore a child's confidence. We collect hair donations to help create free custom wigs for children experiencing medical hair loss. Minimum 12 inches required.

Please fill out all required fields marked with *. Your information is kept private and used only to process your hair donation.

Personal Information

First Name*

Last Name*

Phone Number*

Email Address*

Address

Street Address*

City*

State*

ZIP Code*

Date

Hair Details

Approximate Length*

Age of Donor (if minor)

Comments

Acknowledgment Preferences

How would you like to be acknowledged for your donation? Check all that apply.

Acknowledge via Email

Acknowledge via Social Media

Please Mail Donations To:
Butterflies BBI, 115-69 Farmers Blvd, St Albans NY 11412
Phone: (718) 978-2527 · Email: [email protected]

Your information is kept private and used only to process your hair donation. Butterflies by Blaq Inc.^® is a registered 501(c)(3) non-profit.