Apply – Verma Foundation

Wig Application

If you are undergoing cancer treatment and would like to apply for a free cap wig, please fill out the application below.

Name *

First

Last

Birthday *

When is your birthday? (mm/dd/yyyy)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Cancer Type *

What type of cancer do you have?

Treatment Location *

Where are you being treated? (i.e. Beth Israel, Dana-Farber, MD Anderson, St. Jude's, Johns Hopkins, Mayo Clinic)

Oncologist *

What is the name of your oncologist?

How did you learn about us? *

Proof of Treatment *

Please upload an official letter from your oncologist stating that you are under his/her care and require a wig due to hair loss from ongoing cancer treatment. Letter must be addressed to the Verma Foundation and dated within 30 days of submission. Other forms will not be accepted. (Allowed file extentions: .jpg, .jpeg, .doc, .pdf, .png)