Peak Performance USA - An Asthma Management Program for Schools

Respiratory Therapy Department Application

Now that you have decided to become involved with Peak Performance USA, you need to take the next step and actually register by completing the application below. By registering now you reserve the schools you have identified that you want to work with. By including a list of schools, you avoid any confusion that could happen should another RT in your community want to do the same thing with the same school(s).

This information is also used to reserve the correct number of demonstration kits that you will receive to implement the program. We want to make certain that you have all of the resources you need in plenty of time for a successful launch. Peak Performance USA is a great opportunity for you to use your expertise in lung health, and you are to be commended for deciding to take the initiative to make a difference in the lives of children with asthma.

Please complete the application below:

Contact Information

AARC Member Number

Do you hold the AE-C credential?
Yes No

Name (limit 50 characters)

Hospital/Company Name (limit 50 characters)

Director’s Name (limit 50 characters)

Address (limit 50 characters)

City (limit 50 characters)

State

Leave this field blank

Zip

Email (limit 50 characters)

Telephone

Have you approached any schools about participation in Peak Performance USA?
Yes No

Demographic Information

Name of school district (limit 50 characters)

City of school district (limit 50 characters)

State of school district

Number of schools in district

Number of children with asthma

Number of schools applying for

Names of schools
(Important—please separate school names with commas. Please do not use abbreviations, but spell out all words completely.)

Enter the characters at right:

You receive this kit for each school registered.

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The Peak Performance Kit