School Asthma Action Plan Permission
Student Name
Date of Birth
School Name
Teacher/Homeroom
Parent/Guardian Contact Information
Parent/Guardian 1 Name
Phone
Parent/Guardian 2 Name
Phone
Asthma Information
Asthma Triggers
Medications (at school)
Additional Instructions
Permission
I give permission for my child to carry and self-administer asthma medication as prescribed by their healthcare provider.
Parent/Guardian Signature
Date
Healthcare Provider Signature
Date