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.*

YesNo

How did you discover you had breast cancer*

Self examClinical ExamMammogramOther

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. *

YesNo

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

EmailPhone

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.*

YesNo

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

Classy Sisters Wigs, Once approved you may go in at any time during their normal operating hours, 15620 N 35th Avenue, Suite #4, Phoenix AZ 85053, www.classysisterwigs.com, 602-993-8090 (Preferred Vendor)Tina's Treasures - Once approved you must have an appointment before going in for your wig, 10460 N 92nd St #100, Scottsdale, AZ, 85258, (480) 323-1990Wigwam Wig Shop, 1781 Arizona 69, Suite #59, Frontier Village, Prescott, AZ 86301, (928) 771-8855Paris Wigs,1964 N Alma School Rd #3, Chandler, AZ 85224 Phone:(480) 758-5185Mayo Clinic - 5777 E. Mayo Blvd. Phoenix, AZ 85054 480-342-4830 If you are a Mayo patient please have them contact us directly.

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