Don't be a Chump! Check for a Lump! Wig Out Application Form

Today's Date

MonthDayYear

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail

Phone Number

Area CodePhone Number

Month / year diagnosed with breast cancer

Age Diagnosed

Have you ever applied to our Wig Out program before? Due to our budget we ask that you only apply once in your lifetime.

How did you discover you had breast cancer

Other

How did you hear about our program?

Are you interested in sharing your testimony or pictures of how Don't be a Chump! Check for a Lump! assisted you with a free wig? We also have opportunities for to be on the news, honored at our gala, and exciting events.

How do you prefer we contact you if you are approved?

Please Include a Copy of the First Page of your Pathology Report. If you receive an error "file too large" please include any image or blank image and then email your path report to: info@checkforalump.org

Upload a File

I have included the first page of my pathology report that states the diagnosis of breast cancer. Sorry we can only provide for breast cancer patients.

Please choose the ONE Wig Shop you would like to go to.

Please be sure to completely fill out your application and include a copy of the first page of your pathology report.

Any questions or comments please email info@checkforalump.org or call at 602-688-5232

It is your stories like your own that move people to want to help women like yourself by donating to our progam. Please email any pictures/stories you are comfortable having us share on the internet to info@checkforalump.org