Comprehensive Care for
Chicagoland’s Children with Asthma
Letter of Interest
***When complete,
please fax this form to 773-247-9384 or email to
asthma@mobilecarefoundation.org***
School/Site Name
_______________________________________________________________________________
Address
_______________________________________________________________________________________
City/State/Zip
__________________________________________________________________________________
Telephone number
______________________________ Fax number______________________________________
Email
Address__________________________________________________________________________________
Number of
Students at your Site ____________________________________________________________________
Principal/Director
of Site
_________________________________________________________________________
Assistant
Principal/Director
_______________________________________________________________________
School/Site Nurse
and Days at Location
______________________________________________________________
School/Site
Counselor/Social Worker and Days at Location
______________________________________________
Local School
Council (LSC) President (if site is a school)
_______________________________________________
LSC President
Telephone number
__________________________________________________________________
Name and Title of
Person Completing Form
__________________________________________________________
How did you hear
about Mobile
C.A.R.E.?____________________________________________________________
______________________________________________________________________________________________
Would your
school/site staff be willing to provide dedication and a minimal amount of
support to this program?_____
Signature of
Principal/Director ___________________________________________________________________
Mobile C.A.R.E.
is officially approved and supported by Chicago Public Schools, the
Archdioceses of Chicago,
and the Chicago
Department of Children & Youth Services.
All requests will
be acknowledged and you will be subsequently contacted to obtain further
information.
FOR
OFFICE USE ONLY: Date
rec’d ________ Acknowledged ________ Potential Site________ Unable to
Service________ Start Up Mtg. Date________