2023 Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Interest Form

Parent/Camper Information

Question Title

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

Name

Relationship

Email Address

Alternate Email

City/Town

State/Province

ZIP/Postal Code

County of residence

Phone number

Alternate Phone Number

Question Title

* 2. Please enter name of prospective camper and his/her/their information (Please use separate surveys for multiple campers).

Name

Age of camper

Address

City/Town/Zip code (if Different)

Gender

Email Address (If different from parent/guardian).

Question Title

* 3. What school does your camper attend?

Question Title

* 4. Session Interest: Several camp sessions are available. Please check below all dates camper is available.

Camper can participate June 12-June 16, 2023

Camper may be able to participate in late July

Camper may be able to participate in early August

List any alternate or preferred dates available:

Question Title

* 5. 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

* 6. Technology Information (check all that apply)

Camper will have access to computer and internet during camp

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

Parent/Camper may need camera or microphone

Parent/Camper may need support for technology/computer/internet.

Other (please specify)

Question Title

* 7. I would like to plan a call with the camp director to learn more.

Yes

List best times (days of week, times of day):