1.Please enter your name and contact information.

Name

Email Address

Alternate Email 

City/Town

State/Province

ZIP/Postal Code

Phone Number

Alternate Phone Number

2.What is your school's name, location, and county?

3.What is your role in the school? 

Lead school nurse

Full time school nurse

Part-time school nurse

Nursing/Health support personnel

Other (please specify)

4.Type of information desired:

General information about asthma in teens

General information about the camp

Information on how to host a school-based camp

Information for prospective campers

Other (please specify)

5.How would you like to be involved? (check all that apply)

I would like more information about the camp. 

I would like to volunteer for a school-based camp. 

I would like to support the camp in other ways (list below). 

I have a child and/or friends' children with asthma. 

I would like more information about asthma self-management education.

Other interests (describe):

6.If you know a child with asthma who could be interested in the camp please complete the following:

Name of Prospective Camper

Name of Parent or Family Member

Email address

Phone 

City/Town

State/Province

ZIP/Postal Code

7.Do you have any other questions or comments about the Virtual Young Teen Asthma & Wellness Camp?