Asthma Program Scholarship Interest Form

Background Information

Thank you for your interest in becoming an Open Airways for Schools or Kickin' Asthma Facilitator! Please complete the short survey below- we will reach out within 1 week of your submission!

1. Name *This question is required.

2. Email *This question is required.

3. What is the best way to contact you? *This question is required.

4. Phone Number

4. City *This question is required.

5. State *This question is required.

6. Current Role or Employer *This question is required.

7. Which best describes the population you serve? (Select all that apply)

A community with a high prevalence of asthma
A community with a high rate of asthma exacerbations
A community with a high number of emergency department (ED) visits and hospitalizations for asthma
A school serving a high percentage of children with asthma
A medically underserved or low-income community
Other