#AMPEDFORSUMMER Entry Form UPDATE: THIS COMPETITION IS NOW CLOSED. Question Title * 1. Contact Details: Name and Surname Street Address City/Town State/Province ZIP/Postal Code Country Email Address Cellphone Number Question Title * 2. What is your age? 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 3. How long have you been an amputee? Less than 2 years 2 to 5 years Longer than 5 years Question Title * 4. What is the reason for your amputation? Trauma Vascular disease such as diabetes Cancer Other (please specify) Question Title * 5. Level of amputation: Above-Knee Amputation Below-Knee Amputation Hemipelvic Amputation Through-Knee Amputation Other (please specify) Question Title * 6. Where did you first hear about Össur? Hospital Prosthetist Doctor Social media e.g. Facebook, Twitter or Instagram Internet search Word of mouth from another amputee Cannot remember Other (please specify) Question Title * 7. Would you be interested to attend a Mobility Clinic to help teach you how to use your prosthetic device better? Yes No Question Title * 8. Upload your #AMPEDFORSUMMER photo here: (By uploading your photo you agree to your photo being published on Össur SA’s Facebook Page.) PDF, JPEG, JPG, PNG, GIF file types only. Choose File Choose File No file chosen Remove File (By uploading your photo you agree to your photo being published on Össur SA’s Facebook Page.) Question Title * 9. Enter the text caption of your #AMPEDFORSUMMER post here: (By entering the text of your post you agree to it being published on Össur SA’s Facebook Page.) Question Title * 10. Would you like us to contact you with information about new products, upcoming events, tips to use your prosthesis and other information? (We promise not to abuse this privilege.) Yes No DONE