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Name (First, Mi, Last):
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Date of Accident: Month: Date: Year:
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Injury type and level: Type: Level:
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When they first get injured many people like to hear about the personal stories of people who have gone through similar experiences.

Thank you for being willing to share your experience.

The form below is to help us get started in the process of having you share your information. After we receive this form we wil contact you to finalize the information you would like to share, and to build a web page for you. The information you provide us here will not be revealed our shared with anyone without your permission.

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Kurt, who has a C5-C6 spinal cord injury from a high school wrestling match, developed the UPPERTONE and our other products.

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