LLAM Recognition Form

Complete the information below to have your submission reviewed for a chance to be featured on Hanger Clinic’s Recognition Board and social media channels. Both you and the person you are recognizing do not have to be Hanger Clinic patients to participate.

NOTE: The only information that will be published from this form is your name, the name of the person you are recognizing, your submission, and select photos you share.

For any questions, please reach out to socialmedia@hanger.com. To learn more about the Amputee Coalition and other ways to get involved during LLLDAM, visit the resource here.

Background and Contact Information:

Your Full Name: *

Your limb loss or limb difference level:

Your Instagram handle:

Your email address: *

__________________________________________________________________________________________________

The full name of the person you are recognizing: *

Their limb loss or limb difference level: *

Their contact information (Either Instagram handle or email address). Note: We will contact the person you are recognizing and share your submission with them. *

Are they a Hanger Clinic patient? Note: This question is to determine if they need to sign an additional PR HIPAA release form. *

Yes

Unknown

Submission Materials:

Please share how this person has inspired you to elevate in 2-5 sentences: *

Please attach 1-3 photos of the person you are recognizing (if you have some of both of you together, awesome, but if not, just the person you are recognizing is fine): (max file size 100MB) *

Consent Forms:

Have you signed the Media / Photo Release form below, which allows us to share your submission publicly? (The release is required to participate.)

Media Release *

Yes

Are you a Hanger Clinic patient? *

Yes

If “yes,” you are a Hanger Clinic patient, you also need to sign the PR HIPAA release form below. (Required)

PR HIPAA Release

Check below if you would like to receive updates from Propel, Hanger Clinic’s patient blog. *

Yes