Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form (ages 11-15) Survey

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.

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.

Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form (ages 11-15)

Parent/Camper Information