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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.
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* Indicates required question
Does your child have asthma?
*
Yes - please complete this form.
No - You do not need to complete/submit this form.
Maybe - please complete this form.
Child First Name
*
Your answer
Child Last Name
*
Your answer
Child Date of Birth
*
mm/dd/yyyy
MM
/
DD
/
YYYY
Gender
*
Male
Female
Other:
Race
Black
White
Asian
Mixed - Black & White
Black and other
White and other
Other:
Clear selection
Parent/Guardians Name
*
Your answer
Parent/Guardian EMAIL
*
Your answer
Parent/Guardian Primary Phone #
*
Your answer
Child's Doctor
*
Your answer
Child's School (pick from list) for 2021-2022 year
*
Choose
(Preschool) - DEVONSHIRE PRESCHOOL
(Preschool) - LAGOON PARK PRESCHOOL
(Preschool) - LYCEUM PRESCHOOL
(Preschool) - PROSPECT PRESCHOOL
(Preschool) - SOUTHAMPTON PRESCHOOL
(Preschool) - ST. DAVID'S PRESCHOOL
(Preschool) - ST. GEORGE'S PRESCHOOL
(Preschool) - ST. PAUL'S PRESCHOOOL
(Preschool) - VICTOR SCOTT PRESCHOOL
(Preschool) - WARWICK PRESCHOOL
(Primary) - DALTON E. TUCKER
(Primary) - EAST END PRIMARY
(Primary) - ELLIOT PRIMARY
(Primary) - FRANCIS PATTON PRIMARY
(Primary) - GILBERT INSTITUTE
(Primary) - HARRINGTON SOUND PRIMARY
(Primary) - HERON BAY PRIMARY
(Primary) - NORTHLANDS PRIMARY
(Primary) - PAGET PRIMARY
(Primary) - PORT ROYAL PRIMARY
(Primary) - PROSPECT PRIMARY
(Primary) - PURVIS PRIMARY
(Primary) - SOMERSET PRIMARY
(Primary) - ST. DAVID'S PRIMARY
(Primary) - ST. GEORGE'S PREPARATORY
(Primary) - VICTOR SCOTT PRIMARY
(Primary) - WEST END PRIMARY
(Primary) - WEST PEMBROKE PRIMARY
(Middle) - CLEARWATER
(Middle) - DELLWOOD
(Middle) - SANDY'S SECONDARY MIDDLE
(Middle) - T N TATEM
(Middle) - WHITNEY INSTITUTE
(Senior) - CEDARBRIDGE
(Senior) - THE BERKELEY INSTITUTE
(Alternative) - DAME MARJORIE BEAN HOPE ACADEMY
(Alternative) - SUCCESS ACADEMY
(Private) - BERMUDA HIGH SCHOOL
(Private) - BERMUDA INSTITUE
(Private) - MOUNT SAINT AGNES
(Private) - SALTUS GRAMMAR SCHOOL
(Private) - SOMERSFIELD ACADEMY
(Private - WARWICK ACADEMY
HOME-SCHOOL
Other
Child's Year/Class Level
*
(example: Primary 1, Foundation, IB2, Grade 3, Kindergarten, Middle 3, etc...)
Your answer
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