Gift Hair and Gift Confidence Online Form

Name

Age

Gender
MaleFemaleOther

Address

Passport size photograph of the donor.

Mobile number

Email ID

Name of parent/relative/guardian

Mobile number of parent/relative/guardian

Date of the hair cut

Date of courier/delivery of donation

Details of the chemical treatments on the hair (if any)

How did you hear about us?
WebsiteMediaFriendOther

In order to track your donated hair, provide the Courier Company Tracking Number?

Would you like to receive The Cherian Foundation Newsletter through email to know about our other activities?
YesNo

Have you donated your hair before?
YesNo

If yes, Specify

Can we have your consent to publish your name, photograph and comments in our website/ social media/ events and campaigns?
YesNo

If yes, please upload your photograph

Would you like to receive our Acknowledge certificate?
YesNo

Comments (If Any)

Declaration
I hereby confirm that I out of my free will and consent agree to donate my hair to Gift Hair Gift Confidence, Hair Donation Campaign for the sole purpose of the donated hairs to be turned into wigs for marginalized cancer patients undergoing Chemotherapy.I hereby confirm that all information provided by me under this Hair Donation Consent Form is true and correct to the best of my knowledge. I shall ensure that my donation is not in violation of any applicable laws.I hereby confirm that the consent accorded by me under this form is out of my own free will and that neither I nor my representatives shall hold The Cherian Foundation liable for any claims or loss that may arise on account of (a) my consent accorded under this Form or (b)my actions undertaken pursuant to this Gift Hair Gift Confidence programme.I hereby confirm that the consent accorded by me for the use of my photograph and name for the sole purpose of the hair donation drive in social media platforms is out of my own free will.I hereby confirm that I shall be bound by the Privacy Policy and the Terms and Conditions of The Cherian Foundation made available at.

Additional Declaration by the Parent / Guardian if the sponsor is under 18 years:
I hereby confirm that the I do not have any objections to my ward donating his/her hair under this Hair Donation programme and that neither I nor my representatives shall hold The Cherian Foundation Liable for any claims or loss that may arise on account of (a) the consent accorded under this Form or (b)the actions undertaken by my ward or me pursuant to this Hair Donation programme.

Additional Declarations in case of Foreign Donor:
I agree and undertake to bear the duty charges applicable in my country and in India failing which my donation will not be collected by The Cherian Foundation.I shall ensure that my hair donation package mentions that the package contains human hair for charity.I shall ensure prior intimation of my donation to The Cherian Foundation, so that all necessary clearances may be obtained.

Note: Please carefully read the below ‘Hair Donation Guidelines’ at the end of the Form before filling and submitting this hair donation consent form

HAIR DONATION GUIDELINES

1. PRE REQUITES FOR HAIR DONATION:

(a) The length of hair needs to be 10 inches;
(b) Hair needs to be natural – no permanent or semi-permanent hair dye.

2. CUTTING OF HAIR:

(a) Ensure that prior to cutting, the hair is clean and dry;
(b) Cut hair is to be tied hair in pony tail or braided with rubber band;
(c) Any hair swept off the floor or shaved without being bundled in a ponytail cannot be used.

3. COURIERING THE DONATIONS:

(a) the cut hair is to be placed in plastic bag;
(b) place the plastic bag in an envelope that would hold the weight of the hair donated and seal
the same;
(c) the package is to be couriered to or may be dropped off at:
The Cherian Foundation
No. 38, Malony Road,
T. Nagar, Chennai – 600 017
TEL. 044 – 4040 4444