Hair Donation Form
Donor's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the color of your hair?
Light Brown
Dark Brown
Blonde
Red
Black
Upload a photo of your hair (before)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a photo of the cut hair (after)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What are your reasons for donating your hair?
Date of Hair Cut
-
Month
-
Day
Year
Date
Name of the Salon
I confirm to the following:
I confirm that my hair was not treated chemically.
I confirm that my hair was not colored.
I confirm that I don't have a grey hair
I confirm that my hair is clean and dry
Do you want to be added to the mailing list and receive marketing, news, and updates from us? Don't worry, you can unsubscribe anytime.
Yes
No
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
By signing the form below, I confirm that all information in this form is true and accurate.
Signature
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
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