Thank you for your interest in participating in this book!

After completing this form, please email a photo of your child engaging in the activity as it relates to questions 9 & 10 to LibbiChilia@yahoo.com.  Add your child's name to the subject line.

While it is my hope to include every submission, it may not be possible.  Please make sure information is correct and complete.  For parents of young children, please feel free to assist your child in answering questions.  Older children and teens, please complete in your own word.  I will need a parent/guardian signature for all accepted submissions of children under the age of 18.  I prefer submissions be about children ages 8-18.

The purpose of this book is to offer inspiration to families of children with limb differences and to dispel prejudices.  It is my intent to portray all submissions in a positive light.  My first book, Imagine…Amazing Me! is appropriate for the younger reader.  I am hoping that this book, still untitled, will be appropriate for older children.

Finally, I appreciate your submission.  All proceeds from the book are given to benefit children with limb differences.  A few organization that I have to donated include:  iShine, Achievement Centers for Children, and the Children's Amputee Network.  It is my intent to continue to donate to these types of organization.  Therefore, people who are portrayed in the book are not paid.  By submitting your story and photo, you are also stating that you accept those terms.  You WILL receive a free book.
Please submit survey by November 19, 2017

* 1. What is your First and Last name? (only first name will be used in the book)

* 2. How old are you?

* 3. What are your Parent/Guardian's first and last Name?

* 4. What grade are you in school?

* 5. At what email address would you like to be contacted?

* 6. What is your phone number?

* 7. What is your address?  (Only your state/country will be published in the book)

* 8. Why type of limb difference(s) do you have?

* 9. What activities do you enjoy doing that some people would think that you couldn’t do because of your limb difference?

* 10. Please respond, in 200 words or less, to one of the prompts as it relates to one of your favorite activities listed above.  Please use personal experiences.  As the author of the book, I would like to use the words of our children.  I promise to give credit to the children. I also reserve the right to paraphrase the responses.  All entries will have an opportunity for a final review before publishing. (Remember to email me a photo!)

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