School Nurses' Interest Form Virtual Young Teen Asthma & Wellness Camp (VYTAWC)

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* 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

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

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* 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)

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* 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)

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* 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):

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* 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

School Nurses' Interest Form Virtual Young Teen Asthma & Wellness Camp (VYTAWC)

Question Title

* 1. Please enter your name and contact information.

Question Title

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

Question Title

* 3. What is your role in the school?

Question Title

* 4. Type of information desired:

Question Title

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

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

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