Thank you for being interested in learning more about BEAM. Please fill out the questions below, and a health educator will contact you within 48 hours.  | Gracias por estar interesado en aprender más sobre BEAM. Complete las preguntas a continuación y un educador de salud se comunicará con usted dentro de las 48 horas.
 
Requirements of the program:
  • Have an asthma diagnosis
  • Get a referral or confirmation letter from your doctor's office
  • Be 6 years old and above
  • Live in Los Angeles County
Items and gift cards will only be provided to participants that conduct all in-person/virtual visits. (Virtual visits must have their video camera on)

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* 1. Name/Nombre 

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* 2. Age/Edad

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* 3. Do you live in Los Angeles County? / ¿Vives en Los Ángeles?

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* 4. Date and Time Preference to be contacted: / Preferencia de fecha y hora para ser contactado:

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* 5. Do you have proof of asthma diagnosis? / ¿Tiene prueba de diagnóstico de asma?

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* 6. Phone Number / Número de Teléfono

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* 7. Email / Correo Electrónico

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* 8. How did you hear about this program? / ¿Cómo se enteró de este programa?

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