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Cap Wig Application

The Verma Foundation gives a cap wig free of charge to children 18 years old and under with cancer.
If over 18 years old, we offer a free cap wig based on financial need and approval.

The application process:
-Application cycle closes on the 15th of each month.
-Applications are approved on a case by case basis determined by our board of directors. Please be as specific and detailed in your answers.
-We will reply by email within one week after the application cycle closes if all questions are answered and documents uploaded.
-Please direct any questions, comments, or concerns to contact@vermafoundation.org.

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?

Do you currently have a head covering (wig or cap wig)? *

How would a cap wig help you? *

How did you learn about us? *

Required Documents *

Letter signed by oncologist/wig prescription
Most recent tax returns (if over 18 years old)
Other proof to verify financial status (if over 18 years old)

Please note applications will not be reviewed unless required documents are submitted.

Upload Letter/Prescription *

Click or drag a file to this area to upload.

Please upload a prescription from your oncologist for a wig/cranial prosthesis OR 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. Prescription/letter must be addressed to the Verma Foundation and dated within 30 days of submission. Other forms will not be accepted and will delay your application approval process. (Allowed file extensions: .jpg, .jpeg, .doc, .pdf, .png)

Proof of Income Documents *

Click or drag files to this area to upload. You can upload up to 4 files.

Acceptable documents to show proof of income:
W-2 – Income Statement
1099 – Miscellaneous Income
Federal Income Tax Return
If you do not have income and have no filed taxes, you can request a free “Income Transcript” from the IRS (https://www.irs.gov/forms-pubs/about-form-4506-t)

Would you like to share your story? Testimonials help our non-profit grow and give hope to patients facing cancer. *

Yes, I would like to share my story after receiving my cap wig.
No, I am not interested.

Name

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