Locks 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 (check one):
Visa
Master Card
Check
Credit Card Number: ___________________________________ Exp Date: _____________ Name on Credit Card: ______________________________________
Locks of Love – 2925 10th Avenue North, Suite 102 – Lake Worth, FL 33461 Phone (888) 896-1588 – Fax (561) 963-9914 –
[email protected]
