HaLo Funds Vaucher Application

The Pink Pamper HaLo Fund will provide a one-time voucher in the amount of $350 to help a woman currently going through cancer treatment to buy a hair prosthesis. The HaLo Fund was established to help women who have experienced the trauma of hair loss due to chemotherapy by providing financial assistance in the form of a $350 voucher towards the purchase of a beautiful, natural-looking wig at Hair Enhancements of Pittsburgh. This is vital to these women because when a woman’s hair (her HaLo) is restored, she experiences the very important benefits of increased self-confidence, improved health and creating a more positive outlook about the future.

Kelsie Baldé and Hair Enhancements of Pittsburgh, our exclusive partner in this effort, carries an assortment of helpful accessories including hats, turbans, scarves, hair products and wig supplies in addition to the best synthetic and human hair wigs currently available.

Name(Required)

Date of Birth(Required)

How Did You Hear About Us(Required)

Daytime Phone(Required)

Alternate Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Do You Rent

Rent

Own

Other

Household Information:

List All your household family members as listed on your tax returns

Name(Required)

Age

Name(Required)

Age

Name(Required)

Age

Name(Required)

Age

Name(Required)

Age

Yearly Income Range

$1 - $10,000

$10,000 - $25,000

$25,000 - $50,000

$50,000 - $75,000

$75,000 - $100,000

$100,000 or above

Name of Your Oncologist(Required)

May we pass your name and contact information along to our photographer, Shari Brownlee, owner, Studio M Photography, who will do a photo shoot for you which includes the photo shoot, an 11 x 14 picture, hair, and makeup. Please check your answer:

Yes

No

Disclaimer:

I understand that the information I provide will be kept confidential. I understand that if any information I have given is determined to be false, it may result in not being provided with a voucher.

I agree to fill out a survey prior to me receiving my final fitting of my wig.(Required)

I certify that the above information is true and accurateto the best of my knowledge.(Required)

Signature(Required)

Relationship to patient(Required)

Approval of Voucher Signature(Required)

Voucher Number(Required)

Date(Required)

Pink Pamper HaLo Fund
Voucher Application

Household Information:

Disclaimer:

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Pink Pamper HaLo FundVoucher Application

Household Information:

Disclaimer:

Pink Pamper HaLo Fund
Voucher Application