2024 Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form
[For LIT Registration, GO TO https://www.surveymonkey.com/r/2024LITRegistration ]

Parent/Camper Information

Question Title

* 1. Please enter Name of Camper and his/her/their contact information (Please use separate surveys for multiple campers/LITs).

Name

Age of camper

Home (Mailing) Address

City/Town/Zip code (if Different)

Zip/Postal Code

Gender

School Email Address

Parent/Guardian Email Address

Phone Number

Question Title

* 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).

Question Title

* 3. What school does your Camper attend & grade?

Question Title

* 4. Session Interest: Several 1-week Virtual (Zoom) camp sessions are available. Camps run from 10AM-3 PM with lunch break. Please check below all dates Camper is available.

Camper can participate June 10-14, 2024.

Camper can participate July 8-12, 2024

Camper can participate in either camp.

List any alternate or preferred dates available:

Question Title

* 5. Camper would like to participate in Virtual Asthma Blues Mini-Camp:

Saturday April 13, 10:00-11:30 AM (Central Time) on Zoom

Saturday May 11, 10:00-11:30 AM (Central Time) on Zoom

Saturday June 8, 10:00-11:30 AM (Central Time) on Zoom

Other (please specify)

Question Title

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

Camper is 11-15 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

Question Title

* 7. Technology Information and Needs (Funding available) (check all that apply)

Camper will have access to computer and internet during camp

Camper may need a "Hotspot" or Wi-Fi connection

Camper may need camera or microphone

Camper may need support for technology/computer/internet.

Other (please specify)

2024 Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form [For LIT Registration, GO TO https://www.surveymonkey.com/r/2024LITRegistration ]

Parent/Camper Information

Question Title

* 1. Please enter Name of Camper and his/her/their contact information (Please use separate surveys for multiple campers/LITs).

Question Title

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

Question Title

* 3. What school does your Camper attend & grade?

Question Title

* 4. Session Interest: Several 1-week Virtual (Zoom) camp sessions are available. Camps run from 10AM-3 PM with lunch break. Please check below all dates Camper is available.

Question Title

* 5. Camper would like to participate in Virtual Asthma Blues Mini-Camp:

Question Title

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

Question Title

* 7. Technology Information and Needs (Funding available) (check all that apply)

2024 Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form
[For LIT Registration, GO TO https://www.surveymonkey.com/r/2024LITRegistration ]