Enroll Your Child

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

Head Measurement Chart

Download to measure your child's head before submitting

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.