Asthma Emergency Action PlanChild's Name(Required) Age(Required)Child's Full Name(Required) Date Of Birth(Required) MM slash DD slash YYYY Child's Photo(Required)Max. file size: 2 MB.Parent/Guardian Name(Required) First Last Home Phone(Required) Work Phone(Required) Emergency Contact Name(Required) First Last Home Phone(Required) Work Phone(Required) Doctor Name(Required) Phone(Required) What are the symptoms(Required)Medicine(Required)How Much(Required)How(Required)When to contact parent Other Instruction It is parent responsibility to notify the facility of any change in the child's conditionDanger Zone 1) Medicine is not helping 2) Breathing is hard & fast 3) Trouble Speaking Call doctor, if cannot contact take child to emergency 911 inform parent Sign belowPrimary Care Provider(Required) Date(Required) MM slash DD slash YYYY Parent/Guardian(Required) Date(Required) MM slash DD slash YYYY