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2024 Virtual Young Teen Asthma & Wellness Camp (VYTAWC) Camper Interest Form
[For LIT Registration, GO TO https://ww
w.
surveymonkey.com/r/2024LITRegistration ]
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.
Session Interest: Several 1-week Virtual (Zoom) camp sessions are available. Camps run from 10AM-3 PM with lunch break. Please check below all dates Camper is available.
Camper can participate June 10-14, 2024.
Camper can participate July 8-12, 2024
Camper can participate in either camp.
List any alternate or preferred dates available:
5.
Camper would like to participate in Virtual Asthma Blues Mini-Camp:
Saturday April 13, 10:00-11:30 AM (Central Time) on Zoom
Saturday May 11, 10:00-11:30 AM (Central Time) on Zoom
Saturday June 8, 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)
Current Progress,
0 of 7 answered
