YSGOL Y WAUN

ASTHMA FORM

I request that my child…………………………………………………….

in class………………..be given his/her medication for Asthma.

Name of Medication……………………………………………………..

Dosage:……………………………………………………………………

Time to be administered:………………………………………………..

Name and Telephone Number of Doctor:………………………………

…………………………………………………………………………….

SIGNED:……………………………………..

DATE…………………………………………

Any other comments: