*
Required
Asthma Questionnaire
Student's First Name
*
required
Student's Last
*
required
When was your child last asthma attack?
*
required
Does your child use an inhaler regularly?*
Yes
No
Where would you prefer your child's inhaler located during school hours?*
Nurse's office (Please supply the school nurse with an inhaler orientation day.)
With my child
Both (Please supply the 2 inhalers on orientation day.)
Emergency Contact Name
*
required
Emergency Contact #
*
required
Emergency Contact Email
*
required
Please send a confirmation email to the address below*: