Dear Parents:

Providence Academy is committed to promoting a healthy and safe learning environment for each student. According to our records, your child is listed as having asthma. If your child has mild asthma and does not use medication or a rescue inhaler, you will only need to complete the Asthma Individual Health Plan. If your child has had any symptoms in the past year, please complete the following information.

Asthma Individual Health Plan – This form is for parents to complete, no physician signature is required.

Asthma Action Plan – Please provide the health office with a copy of your child’s Asthma Action Plan (AAP). If your child’s physician has not provided you with an AAP, send the Medication Authorization Form to your child’s physician for authorization of any medication they will need at school, such as albuterol, over-the-counter allergy medications, etc. A nebulizer is available during the year should you wish to send in vials and their tubing/mask.

Medication for asthma must be kept in the health office, with the exception of students in grades 6 -12, who may self carry their inhaler. If your child is entering 6-12 grade and wishes to carry their inhaler, please complete the Student Agreement for Self-Administration of Inhaler Medication.

This information is requested annually and shared with the appropriate staff. Please return these forms to the health office as soon as they are available, but no later than August 14th.

If your child no longer has problems with asthma, please notify the health office so that our records may be updated. Thank you for your assistance. Please contact me with any further questions or concerns.


Maureen Murphy, RN, LSN
Licensed School Nurse

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