WIG EXCHANGE PROGRAM 3 Request A Wig 1 Your Info2 Your Info (cont'd)3 Income Info4 Household Info5 Expense Info6 Your Hair7 Agreement Name* First Last Phone*Email Date of Birth* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How did you hear of DD Daughters Wig Exchange Program?Condition*What type of cancer do you have?Treatment Location*Where are you being treated? (i.e. Sibley Memorial Hospital, Johns Hopkins, etc..) Employment Info*Full-timePart-timeRetiredUnemployedIf full-time or part-time employed...*Where do you work? What position do you hold? Enter 'retired' if you are retired and 'unemployed' if unemployed.Income Info*Are you paid hourly or paid a salary?Paid by the hourPaid a salaryIncome Info*How much do you make hourly? If you make a salary, how much do you make annually?Do you receive Supplemental Security Income?*YesNoHow much do you receive in SSI monthly?Do you receive Disability Income?*YesNoHow much do you receive in Disability Income monthly?Marital Status*SingleDomestic PartnerMarriedDivorced / SeparatedWidowedSpouse's Employment Info*Full-timePart-timeRetiredUnemployedHow much does your spouse earn in income monthly? Children & Dependents*How many financially dependent children do you have? Enter '0' for no children.Household Members*Please indicate the total number of people living in your home. Household Income*What is the combined income of ALL members of your household annually?Proof Of Income*Please upload the most recent copy of your W-2 or other proof of income (i.e. Social Security Stub, Welfare Stub, Disability Stub, etc). Drop files here or What is your living situation?*OwnRentLiving with friends or familyLiving (continued)*How much do you pay for rent or mortgage monthly?Household ContributionsPlease indicate which of the following bills you are responsible for and enter the amount you pay or contribute monthly. Auto Payment Auto Insurance Cable and/or Internet Electric Home Insurance Phone Water / Sewer None Auto Payment*How much is your auto payment monthly?Auto Insurance Payment*How much is your auto insurance payment monthly?Cable & Internet Payment*How much is your cable / internet payment monthly?Electric Payment*How much is your electric payment monthly?Home Insurance Payment*How much is your home insurance monthly?Phone Payment*How much is your phone payment monthly?Water Payment*How much is your water payment monthly?DebtPlease indicate which debts you have and the total amounts. Medical Student Loan Credit Card Other None Medical Debt*How much is your medical debt?Student Loan Debt*How much is your student loan debt?Credit Card Debt*How much is your credit card debt?Other Debt*How much is your other debt? Do you have health Insurance?*YesNoHealth Insurance CompensationHow much would your health insurance pay towards a wig, if anything? Have you ever owned a wig?*YesNoDo you currently have a wig?*YesNoYour Natural Hair Quality*How was your hair before you lost it? Check all that apply. Short Shoulder length Long Your Natural Hair Quality*How was your hair before you lost it? Check all that apply. Straight Wavy Curly Your Natural Hair Quality*How was your hair before you lost it? Check all that apply. Thin Medium-Grade Thick Your Natural Hair Quality*What color was your hair prior to losing it?Your Natural HairFeel free to use this space to describe your hair as much as you can, prior to losing it. Other CircumstancesAre there any other circumstances that we should know about? If so, enter here.Your Ideal WigWhat does obtaining/having a high quality wig mean to you?Authorization*By submitting this application, I authorize DDDaughters to verify any and/or all information provided, and by submitting this application, I certify to the best of my knowledge that all information that has been entered and is contained on this form is correct. I understand and agree that if I am selected to participate in the DDDaughters Wig Exchange Program that the answers I supplied to the last question on this application (What does having /obtaining a high quality wig mean to you?) may be used by DDDaughters for promotional purposes, including but not limited to website content. I have read and agree to the above statement. What Happens Next?*Once we receive your application, we will contact you to schedule a follow-up interview. If you qualify for our program, you will be asked to provide at least one photo of yourself and a few head measurements. You will also be asked to submit documentation of your cancer diagnosis and a prescription for a wig from your health care provider. Once a recipient submits their information and the necessary documentation, they will receive their custom wig promptly thereafter. I have read and understood the above statement. Well contact you shortly, prepare for SUCCESS.