Enroll Your Child

Complete the form below to apply for free hair replacement services. Our team reviews every application with care and compassion.

Child's Info

Guardian Info

Address & School

Child's Information

Tell us about the child who needs our services.

Child's First Name*

Child's Last Name*

Date of Birth*

Age*

Gender

Medical Condition*

Approximate Diagnosis Date

How did you hear about us?*

Step 1 of 3

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