FL Asthma-Friendly School Interest Form / Mentor Request

Asthma-Friendly School Mentor Sign-Up

Thanks for your interest in the Asthma-Friendly School Award from the Florida Asthma Coalition!

Please provide the information below and a knowledgeable and friendly mentor will contact you.

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Your Contact Information:

First Name

Last Name

E-Mail Address

Phone Number

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Position / Role (Check all that apply):

Administrator

Teacher / Faculty

Physical Education Teacher

Social Worker / Counselor

School Nurse

Health Tech

Parent / Guardian

School Volunteer

Nutrition Services

Custodial Worker

Bus Driver

School District Staff

Other (please specify)

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Select your district / county:

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School Name:

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School Level (check all that apply):

Pre-K

Elementary

Middle

High

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School Type:

Public

Private

Charter

Other (please specify):

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Is this a Title 1 school?

Yes

Not Sure

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Has your school partnered with the American Lung Association in the past to provide asthma education to students or school staff? (Including the Open Airways for Schools Program)

Yes

Not Sure

Comments

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How did you hear about this recognition opportunity?

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Please provide any additional information about your role at the school, your interest in asthma, or the type of assistance you would like to receive from your Asthma-Friendly School Mentor.