Wig Assistance Program

Lala's Wings Application
& Waiver Packet

Providing confidence, dignity, and support to individuals undergoing cancer treatment through the gift of free wigs.

Back to Programs Program Overview

About the Program

Lala's Wings is a nonprofit organization dedicated to supporting individuals battling cancer by providing high-quality wigs at no cost to eligible patients experiencing hair loss due to cancer treatments such as chemotherapy or radiation.

"To restore confidence, dignity, and hope to cancer patients during one of the most difficult journeys of their lives."

Because wigs are purchased through charitable funding, supplies may be limited and subject to availability. Submitting this application does not guarantee approval, but every effort will be made to assist qualified applicants.

Requirements

Eligibility Requirements

To qualify for the Lala's Wings Wig Assistance Program, applicants must:

Applicants must be:

Physician Medical Verification Required

After submitting your application, we will follow up to request a completed Physician Medical Verification Form. You can download it now to bring to your next appointment.

Download Form →
Application

Complete the Application

Please complete all sections below. Fields marked with * are required. Your information will be kept private and used solely for program eligibility and administration.

Applicant Information

Section 1 of 4

Preferred Method of Contact *

Emergency Contact

Section 2 of 4

Medical Information

Section 3 of 4

Are you currently receiving treatment? *
Type of Treatment *

Wig Preferences (Optional)

Section 4 of 4

Hair Color Preference
Hair Length Preference
Hair Texture Preference

Liability Waiver & Release

Please read carefully before signing

By submitting this application, I acknowledge and agree to the following:

  • I understand that wigs provided by Lala's Wings are purchased through charitable contributions.
  • Lala's Wings makes no medical claims regarding the wigs provided.
  • I acknowledge that wigs are cosmetic accessories and are not medical devices.
  • I voluntarily accept the wig provided and assume any risks associated with wearing it.
  • I release and hold harmless Lala's Wings, its directors, volunteers, donors, and affiliates from any liability related to the use of the wig.
  • I understand that wigs are non-returnable and non-exchangeable unless determined otherwise by the organization.

Photo / Media Release (Optional)

Lala's Wings shares stories to inspire hope and raise awareness for cancer patients. If permission is granted, images may appear on social media, our website, fundraising campaigns, and awareness materials. No compensation will be provided for such use.

Privacy Statement

Lala's Wings respects your privacy. All personal and medical information provided in this application will be used solely for determining program eligibility, internal recordkeeping, and program administration. Information will never be sold or shared with third parties without consent, except where required by law.

Applicant Agreement

By submitting this form, I certify that:

  • The information provided in this application is accurate and truthful.
  • I understand that submitting an application does not guarantee approval.
  • I agree to the terms outlined in this packet.

If Applicant is a Minor:

After submitting, a confirmation will be sent to your email.
Questions? Contact us at lalaswings501@gmail.com or (224) 698-1383