#AMPEDFORSUMMER Entry Form

UPDATE: THIS COMPETITION IS NOW CLOSED.

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* 1. Contact Details:

Name and Surname

Street Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Cellphone Number

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* 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

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* 3. How long have you been an amputee?

Less than 2 years

2 to 5 years

Longer than 5 years

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* 4. What is the reason for your amputation?

Trauma

Vascular disease such as diabetes

Cancer

Other (please specify)

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* 5. Level of amputation:

Above-Knee Amputation

Below-Knee Amputation

Hemipelvic Amputation

Through-Knee Amputation

Other (please specify)

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* 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)

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* 7. Would you be interested to attend a Mobility Clinic to help teach you how to use your prosthetic device better?

Yes

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* 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

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* 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.)

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* 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