Asthma Blues Mini-Camp Registration

Parent/Camper Information

Question Title

* 1. Please enter Name of Mini-Camp Participant and his/her/their contact information (Please use a separate surveys for each camper). Recommended for campers 6-18 years.

Name

Age of camper

Camper Email Address

Home or Mailing Address

City/Town

Zip/Postal Code

Gender

Camper's School Email Address

Parent/Guardian's Email Address

Phone Number

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* 2. Please enter name of parent/guardian, relationship, and contact information.

Name

Relationship

Email Address

Alternate Email

City/Town

ZIP/Postal Code

County of residence

Parent/Guardian Cell Phone Number

Alternate Phone number

Which do you prefer: Call by phone (cell) or Text (cell).

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* 3. What is your camper's School & current Grade?

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* 4. Mini-Camp Session Interest: The Mini-Camp is a virtual interactive camp, held the second Saturday of the month (online) from 10:00-11:30 AM (Central Time). Campers receive the digital music to download prior to camp. Camper may attend multiple camps. Check all that apply.

Camper can participate November 9, 2024.

Camper can participate December 14, 2024

January 12, 2025

February 9, 2025

March 9, 2025

April 13, 2025

May 11, 2025

List any alternate or preferred dates available:

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* 5. Please verify the following (Check for Yes):

Camper is 6-18 years old with diagnosed asthma

Camper will have appropriate supervision during camp.

Parent/Guardian will support Camper in sustaining asthma self-management skills.

Camp Director/Team may contact parent by email and/or text message. Please add Camp Director to contacts or safe list. Ellen Buckner 205-910-9877, ebbuckner@gmail.com

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* 6. Technology Information (check all that apply)

Camper will have access to computer and internet during camp (required for Mini-Camp)

Other Needs (please specify)

Asthma Blues Mini-Camp Registration

Parent/Camper Information

Question Title

* 1. Please enter Name of Mini-Camp Participant and his/her/their contact information (Please use a separate surveys for each camper). Recommended for campers 6-18 years.

Question Title

* 2. Please enter name of parent/guardian, relationship, and contact information.

Question Title

* 3. What is your camper's School & current Grade?

Question Title

* 4. Mini-Camp Session Interest: The Mini-Camp is a virtual interactive camp, held the second Saturday of the month (online) from 10:00-11:30 AM (Central Time). Campers receive the digital music to download prior to camp. Camper may attend multiple camps. Check all that apply.

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* 5. Please verify the following (Check for Yes):

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* 6. Technology Information (check all that apply)

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* 7. Has parent/camper received any form of asthma education from a provider or clinic? If so, please describe.

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* 8. What challenges or problems about asthma would you like to have addressed?

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* 9. Do you have any other questions about the camp? Thank you for your interest!