Hair Donation Form - Locks Of Love
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1Locks of Love
Hair Donation Form
Please complete, print and send this form with your hair donation; you may remain anonymous if
you wish. Please print legibly so we will be able to send you an acknowledgement. Please note,
to receive an acknowledgement may take up to 90 days. If you are sending a photo with your
donation please write your name, address, and phone number on the CD, disk, or back of the
photo in addition to this completed form.
Please measure your ponytail(s) and write the length in inches on the outside of each clear re-sealable bag.
Your Information
_______________________________________________________
Your Name:
_____________________________________________________
Street Address:
________________________________________________________
Apt / Suite:
_______________________________
_________
____________
:
:
City
State
Zip:
__________________
______
____________
Country:
Age (If Minor):
Daytime Phone:
_________________________________________________
How did you find us?
Today's Date: ____________________________________________________
If you would like to make a financial donation, please complete the following section also.
I would like to donate...
$25
$50
$75
$100
Other: ________
I would like to sponsor a Locks of Love child for $1,000!
We gladly accept these
:
Visa
Master Card
Check
(check one)
Credit Card Number: ___________________________________ Exp Date: _____________
Name on Credit Card: ______________________________________
th
Locks of Love – 2925 10
Avenue North, Suite 102 – Lake Worth, FL 33461
Phone (888) 896-1588 – Fax (561) 963-9914 –
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