* 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*: