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Contact Us
About Brendon
Impact
Events
Fundraisers
Benefit Concert
BMAC Memorial Tournament
Run4Ten
Asthma
Donate
Contact
Contact Us
School Forms
DISTRICT INFORMATION
School District
*
Number of school sites in district:
*
Superintendent Name
*
District Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
District Phone
*
(###)
###
####
Fax Number
*
(###)
###
####
School District Type
*
Public
Charter
Private/Parochial
Grades Served
*
PRIMARY HEALTH OFFICE CONTACT
Health Personnel Name
*
First Name
Last Name
If Applicable: Licensure/Certification:
*
Email
*
Phone
*
(###)
###
####
Type of Health Office Personnel:
*
Select all that apply
NP
RN
LPN
CN
Health Assistant
Other
AS OF THE BEGINNING OF THE PAST SCHOOL YEAR (2021-2022)
No. of Students:
*
% Students that Qualify for Free & Reduced Lunch Assistance:
*
% of Hispanic / Latino Students:
*
No. of Asthmatic Students:
*
No. of Students with a Personal Rescue Inhaler at School:
*
No. of 911 Calls Last School Year (2021-2022):
*
No. of Asthma-related 911 Calls Last School Year (2021-2022):
*
No. of EMS Transports Last School Year (2021-2022):
*
No. of Asthma-related EMS Transports Last School Year (2021-2022):
*
*The program manager will contact each participating school at the end of the 2022-2023 school year to ask these same questions about this school year. Collecting information about your school before and after the Stock Inhaler for Schools Program will allow our team to evaluate the program. Such evaluations may help secure additional funding and ensure program sustainability. If you have any questions about data collection, please e-mail bmacmemorialfoundation@yahoo.com
LIST SCHOOL NAME AND AT LEAST 2 TRAINED PERSONNEL MEMBERS AND TITLES FOR EACH SCHOOL IN THE DISTRICT RESPONSIBLE FOR ADMINISTRATION OF STOCK ALBUTEROL MEDICATION
*
(PLEASE SEPERATE SCHOOLS BY LINE BREAK)
***We acknowledge that we have received the appropriate training, supplies, and have designated a minimum of two trained staff members to administer albuterol medication at this school.
*
Agree
***We agree to notify the Brendon McLarty Memorial Foundation 30 days prior to an inhaler expiring and/or need additional disposable spacers.
Agree
Thank you!
