2021/2022 School Asthma Registry Form
To better assist students in Bermuda who have asthma to be healthy and safe at school, we ask that this form is completed for all children (ages 4-18) who have asthma.

This registry is facilitated through a collaboration of The Bermuda Department of Education, The Bermuda Department of Health, The Bermuda Hospitals Board Asthma Education Centre and Open Airways (Bermuda Registered Charity #458).

A SEPARATE FORM form should be completed for EVERY child with asthma in Bermuda.
Does your child have asthma? *
Child First Name *
Child Last Name *
Child Date of Birth *
mm/dd/yyyy
MM
/
DD
/
YYYY
Gender *
Race
Clear selection
Parent/Guardians Name *
Parent/Guardian EMAIL *
Parent/Guardian Primary Phone # *
Child's Doctor *
Child's School (pick from list) for 2021-2022 year *
Child's Year/Class Level *
(example: Primary 1, Foundation, IB2, Grade 3, Kindergarten, Middle 3, etc...)
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy