STOCK INHALER FOR SCHOOLS PROGRAM

STOCK INHALER FOR SCHOOLS PROGRAM

DISTRICT ENROLLMENT FORM | 2024-2025 SCHOOL YEAR
DISTRICT INFORMATION
School District*
Number of school sites in district*
Superintendent Name*
District Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
District Phone*
Please enter a valid phone number.
Fax Number*
Please enter a valid number.
School District Type*

PublicCharterPrivate/Parochial
Grades Served*
PRIMARY HEALTH OFFICE CONTACT
Health Personnel Name *
If Applicable: Licensure/Certification:*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Type of Health Office Personnel*

NPRNLPNCNHealth AssistantOther
AS OF THE BEGINNING OF THE PAST SCHOOL YEAR (2023-2024)
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 (2023-2024)*
No. of Asthma-related 911 Calls Last School Year (2023-2024)*
No. of EMS Transports Last School Year (2023-2024)*
No. of Asthma-related EMS Transports Last School Year (2023-2024)*
*The program manager will contact each participating school at the end of the 2024-2025 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 at each site 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
***We give permission to the Brendon McLarty Memorial Foundation to pick up stock inhalers from the pharmacy and mail them to our school district.*

I agree
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STOCK INHALER FOR SCHOOLS PROGRAM

DISTRICT INFORMATION

PRIMARY HEALTH OFFICE CONTACT

AS OF THE BEGINNING OF THE PAST SCHOOL YEAR (2023-2024)