BREATHE 1-2-3 Application Form

BREATHE 1-2-3 Application Form
Child's Name

First NameLast NameNickname (preferred name)
Age
Grade
Age first diagnosed with asthma
Last hospital visit due to asthma
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email
example@example.com
Parent/Guardian Cell
Please enter a valid phone number.
I would like to apply for the travel subsidy

YesNo
*Subsidy applicants must reside outside of Fraser Valley Regional District and Metro Vancouver Regional District.
Family Physician
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child have allergies?

YesNo
If yes, please list all allergens your child is allergic to:
Reliever (blue)
Reliever dose
Controller (orange)
Controller dose
Other Medication
Do you currently have an asthma action plan?

YesNoUnsure
T-shirt size for child

SmallMediumLarge
Where did you hear about Breathe 1-2-3 Asthma Camp?
Consent Form

Please choose either 1) or 2), below:
1) The BC Lung Foundation would like to make audio and video recordings, and photographs of the session to help us evaluate and improve it. Any audio or video recordings will remain with BC Lung's program team and will not be made public.  I consent to have audio and video recordings made of my children's participation on the condition that they will not be made public.

Clear
Date of Signature
2) BC Lung Foundation would like to take pictures and video recordings to document the sessions and to promote our health programs. I consent to photos being taken during the sessions and for images to be used to promote BC Lung Foundation’s public messaging to support our health programs.

Clear
Date of Signature
Should be Empty:

BREATHE 1-2-3 Application Form

Consent Form