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APPLY FOR CONFIDENT CROWN SUPPORT​

Before submitting your application, please review the eligibility requirements and program information on The Confident Crown Initiative page to determine whether the program may be a good fit for your needs.

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The Confident Crown Initiative provides eligible applicants with hair-loss support based on documented need, available funding, program resources, and the appropriateness of the requested support. Available options may include human-hair wigs, a limited selection of high-quality heat-friendly synthetic-blend wigs, care resources, and custom cranial hair prostheses when appropriate and fundable. Fitting, customization, styling, and installation support may be available through qualified partners but is not guaranteed.

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Complete the application below to begin the review process. Submitting an application does not guarantee approval or a particular hair-replacement option. After reviewing your application, our team will contact you regarding eligibility, available support, and next steps.

Birthday
Month
Day
Year
Are you a U.S. resident?
Yes
No
How did you hear about us?
Family or Friend
Social Media
Doctor or Hospital
Other
Are you applying for:
A child (17 or younger)
An adult (18 or older)

Parent/guardian must apply on behalf of child

What type of hair replacement support are you interested in?
Human-hair wig
High-quality heat-friendly synthetic-blend wig (limited availability)
Custom cranial hair prosthesis
I'm not sure — please help me determine the best option
How would you describe the extent of your hair loss?
Thinning or partial hair loss
Significant hair loss
Complete or near-complete hair loss
Expected treatment-related hair loss
Other
Do you currently have health insurance?
Yes
No
Prefer not to answer
Would you like Lost and Crowned to explore whether your health plan may provide a wig or cranial hair prosthesis benefit?
Yes
No
Not sure

Insurance is not required to qualify for the Confident Crown Initiative. Your answer does not affect program eligibility. If you request insurance-benefit assistance, Lost and Crowned will obtain separate authorization before contacting your insurer or treating healthcare provider.

(paragraph answer)

Would you be willing to share your story or photo publicly to inspire others?
Yes, publicly (with permission)
Yes, anonymously
No
Do you currently have a prescription or medical documentation from a licensed healthcare provider related to your hair loss?
Yes
No
Not yet

Required if you selected “Yes” above. If you selected “No” or “Not yet,” you may leave this blank.

Clear, recent photos required

Confidential use only. Please upload clear, recent photos that show your hair loss and confirm the photos are yours. At least one photo must clearly show your face and the area of hair loss in the same image. Include a full-head photo plus close-up photos of the affected areas or spots. Use good lighting and make sure your face, hair, and scalp are visible. Do not use filters, heavy editing, hats, wigs, or other coverings in the verification photos. You may upload multiple photos.

(PDF/JPG/PNG)

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

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Lost and Crowned, Inc. is a registered 501(c)(3) tax-exempt organization. EIN 41-2371036. Contributions are tax-deductible to the fullest extent permitted by law.

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Florida Registration No. CH81959

Find us: 

1645 Sun City Center Pl. #5004

Sun City Center, FL 33571

Contact us: 

Phone: (813) 922-2097

Email: info@lostandcrowned.org

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