Asthma Action Plan

For prescribed puffer use due to asthma or other lung diseases.

Please fill out to provide our staff all the information required to ensure the well-being of your child.

NOTE: In the case of an asthma attack our protocol is to call 911 and follow the allergy action plan provided.

Childs Name

First Name

Last Name

Childs Date of Birth

YYYY

*For maintenance inhalers only*

Medication name on label, times to administer and dosages to be administered.

*For emergency use inhalers*

Medication name on label, dosage to be administered including time between puffs.

Please list if there are any triggers that should be avoided due to your child's asthma.

ASTHMA ACTION PLAN

please list in details what you do in the case of an asthma attack. Keep in mind we always call 911 with all asthma attacks.

Caregivers Name

This is the first point of contact from our camp in case of an emergency.

First Name

Last Name

Caregivers Phone Number

(###)

###

####

Todays Date of Consent Given

YYYY

Terms and Conditions

Medication must be all be in original named box / bottle and always labelled with the child’s name, DOB, dose and date. (dispensed from the pharmacy). Please supply a measured medicine spoon/syringe or chamber. Please give staff all the information required to insure the well-being of the child. At least one dose of the medication has already been administered and my child has not suffered any unwanted reactions. All forms should have clear and specific reasons, signs & symptoms. Our day is 24hrs day so 3 times/day means every 8hrs, unless stated by the GP. Staff will log in medication administration by family. Please note in the case of every asthma attack our protocol is to call 911 and follow the allergy action plan provided.

I agree to the terms and conditions