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Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form (ages 11-15)
Parent/Camper Information
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
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).
3.
What school does your Camper attend & grade?
4.
Future Camps: Please check those you might be interested in.
Summer 1 week virtual camp (June or July)
Spring Break Virtual Camp (March)
Fall Break Camp (October)
Asthma Blues Mini-Camp (Live, Virtual, Second Saturday 10:00-11:30 CT)
School-Ready Camp (August or September)
List any alternate or preferred asthma & wellness camps you would be interested in participating in.
5.
Camper would like to participate in Virtual Asthma Blues Mini-Camp (Second Saturday, 10-11:30 AM Central Time, Virtual, No Charge but must register at separate link):
Saturday April 12, 10:00-11:30 AM (Central Time) on Zoom
SaSaturday May 10, 10:00-11:30 AM (Central Time) on Zoom
Saturday September, 10:00-11:30 AM (Central Time) on Zoom
Saturday October, 10:00-11:30 AM (Central Time) on Zoom
Saturday November, 10:00-11:30 AM (Central Time) on Zoom
Saturday December, 10:00-11:30 AM (Central Time) on Zoom
Saturday January, 10:00-11:30 AM (Central Time) on Zoom
Saturday February, 10:00-11:30 AM (Central Time) on Zoom
Saturday March, 10:00-11:30 AM (Central Time) on Zoom
Saturday April, 10:00-11:30 AM (Central Time) on Zoom
Saturday May, 10:00-11:30 AM (Central Time) on Zoom
Other (please specify)
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
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)
For More Information or to discuss, contact Ellen Buckner, ebbuckner@gmail.com (205) 910-9877.
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