Kids like you and me submission form

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Date conversion02.03.2017
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Want to see YOUR story and picture or video on our website?

Inspire Other Kids and Teens By Submitting Your Personal Story!
Once you have filled out this document in full, please email it to
Name _______________________________________ Age _______
Address __________________________________________
City, State, Country, Zip _____________________________________
Phone ____________________ E-Mail Address______________________
I am a boy/young man _______I am a girl/young woman _____ (check one).
I was diagnosed with asthma at age _____.
I attend elementary/middle school ______ high school ______ college____ graduate school_______ none of the above _______ (check one).
1) Describe the various kinds of physical exercise you like to do.

2) List the sports you play or activities that you do. Please include your favorite event and/or the specific position.

3) What words of advice or encouragement would you offer fellow athletes and physically active young people your age that compete or exercise with asthma?

4) Describe what you do on a daily basis as an individual with asthma that you feel helps improve your physical exercise and/or athletic performance?

5) Briefly tell BEPH why you want to submit your personal story.

6) PLEASE submit either a VIDEO or HIGH RESOLUTION photo of yourself along with this form.

Breathe Easy Play Hard (BEPH) Foundation reserves the right to publish an individual’s submitted profile for consideration and inclusion as an “Kids Like you and Me” on its website at its sole discretion.

An individual and/or their consenting parent or guardian agrees to indemnify (with express written and verbal consent) any submission to “Kids Like You And Me” and hold harmless BEPH from and against any and all losses, claims, damages, expenses or liabilities which may be incurred by the individual and/or their consenting parent or guardian based on information, representation or data furnished by individual and/or their consenting parent or guardian to the extent such material is furnished or approved by the individual and/or their consenting parent or guardian for BEPH use.

All submissions MUST have a parent or guardian consent signature and phone number, signed below.
Name of Child or Teen: _________________________________________
Signature of Child or Teen:­­­_______________________________________
Name of Parent or Guardian: ______________________________________
Signature of Parent of Guardian: __________________________________
Date: ________________________

Phone: _______________________ Email:_________________________

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