2021 VYTAWC Interest Form

Question Title

* 1. Please enter name of prospective camper & contact information.

Name

Age of camper

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Male or Female

Email Address

Phone Number

Question Title

* 2. Please enter name of parent/guardian, relationship, and any contact information that is different from camper.

Name

Relationship

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 3. Session Interest: Which Sessions can camper attend? (Check all that apply)

June 14-18, 2021

July 12-16, 2021

List other dates preferred if we add weeks:

Question Title

* 4. Please verify the following:

Camper is 12-15 years old with diagnosed asthma

Camper will have access to computer and internet during camp.

Camper will have appropriate supervision during camp.

Camper and Parent/Guardian will commit to full participation for the camp.

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

Question Title

* 5. How did you learn about the camp?

Primary Care Provider

Allergist or Asthma Specialist

Medicaid Care Coordinator or Nurse

School Nurse/Principal/Teacher

Other (please specify)

Question Title

* 6. Please list the primary healthcare provider for your child/camper (pediatrician, asthma specialist, MD/NP/PA, health department, etc.) .

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

May we contact them for an Asthma Action Plan?

Email Address

Phone Number

Question Title

* 7. Electronic Signature of Teen & Parent/Guardian (Just type your names to sign).
Thank you for your interest in the 2021 Virtual YTAWC!
Contact Ellen Buckner for questions: ebbuckner@gmail.com (Put Asthma Camp in Subject Line).

2021 VYTAWC Interest Form

Question Title

* 1. Please enter name of prospective camper & contact information.

Question Title

* 2. Please enter name of parent/guardian, relationship, and any contact information that is different from camper.

Question Title

* 3. Session Interest: Which Sessions can camper attend? (Check all that apply)

Question Title

* 4. Please verify the following:

Question Title

* 5. How did you learn about the camp?

Question Title

* 6. Please list the primary healthcare provider for your child/camper (pediatrician, asthma specialist, MD/NP/PA, health department, etc.) .

Question Title

* 7. Electronic Signature of Teen & Parent/Guardian (Just type your names to sign). Thank you for your interest in the 2021 Virtual YTAWC! Contact Ellen Buckner for questions: ebbuckner@gmail.com (Put Asthma Camp in Subject Line).

* 7. Electronic Signature of Teen & Parent/Guardian (Just type your names to sign).
Thank you for your interest in the 2021 Virtual YTAWC!
Contact Ellen Buckner for questions: ebbuckner@gmail.com (Put Asthma Camp in Subject Line).