Form

2011 BORP Summer Energy Challenge

This summer we are challenging 50 kids with physical disabilities to do something amazing. These kids will push their wheelchairs and ride adapted bicycles over 2000 miles, and while participating in BORP activities they will burn over 250,000 calories. This Challenge will be a shining example of what kids having physical disabilities can accomplish when they work together. We are asking you to help us locate these 50 kids. Each kid participating in the Challenge that meets minimum requiremnets will receive a Certificate of Completion. All kids meeting milestones related to miles traveled or program attendance will receive Recognition Awards.

Nominate Someone Today!

We are inviting you to nominate one student from your school to take part in this challenge. Any student with a physical disability or orthopedic impairment that has the ability to ride an adapted bicycle, push a manual wheelchair, or skate in a hockey sled can take part in this challenge. Participating kids DO NOT need to be using a wheelchair permanently. We will provide sports equipment to enable them to participate. In some cases we can even provide transportation. Participants must be motivated and be able to follow instruction.

Student's first name*

Student's Last name*

School*

Grade

Gender

Male Female

Age

Birth Date

Month Day Year

Student's disability or Orthopedic Impairment*

I am nominating this student because:

Sports Opportunities:

This student will be successful in:

Wheelchair Basketball Adapted Cycling Sled Hockey

Nominator, please provide your information below. We will contact you initially to enroll this student in the program or you can provide contact information for the parents.

Nominator's Name*

Phone Number*

- Area Code Phone Number

E-mail*

Can we contact the parents directly?*

Yes No, contact the nominator.

Parent's Name

Phone Number

- Area Code Phone Number

E-mail

Enter the message as it's shown*

Nominate a Student (or someone you know)