Parent’s Name
Address
	Postcode/Zip		Country
Telephone
Email address
Child’s Name
Age of Child
Head/Principal’s Name
Telephone number
Email address
School
School Address
	Postcode/Zip		Country
School website (if applicable)	http://
Child’s current medications:
Child’s relevant medical history:
How does your child’s asthma affect their day-to-day life?
Has your child ever been hospitalised due to their asthma condition? If so, please give details.

For the Parent - Disclaimer:

I agree to give Yamoa Powder to my child as directed by Yamoapowder.com. I will not reduce or cease my child’s medication without my child's doctor’s consent. I will continue to ensure that my child carries their emergency medication with them AT ALL TIMES even if symptomatic relief is found from the use of Yamoa Powder. I have read the Frequently Asked Questions on the Yamoapowder.com website and understand that Yamoa is not a cure for all. I have read the Yamoapowder.com disclaimer.

I take full responsibility for the health and wellbeing of my child and I will not hold Yamoapowder.com or Not the Norm Limited responsible if my child should suffer any unforeseen adverse reaction. In such an event, I shall seek medical assistance immediately and cease to give my child Yamoa powder. I shall also inform Yamoapowder.com of any adverse reaction. 

I agree to provide Yamoapowder.com with written feedback regarding my child’s experience with Yamoa when the first supply has been used. I shall allow Yamoapowder.com to use this feedback in any way it deems necessary to encourage other parents to try Yamoa for their own children, whilst at the same time wholly respecting my and my family’s privacy and keeping all our personal contact details secure.

Signed___________________________    (parent)

Date_____________________________

For the attention of School Principal/Head

I agree to provide all parents of children with asthma in my school with the YAMOA^® for Children Scheme brochure. By doing so, I acknowledge that I will enable parents of asthmatic children to make an informed, independent decision as to whether they wish to join the YAMOA for children scheme. This in no way means that I endorse Yamoa Powder, and yamoapowder.com will not be at liberty to use this agreement in any way as an endorsement of the YAMOA product.

Principal’s Signature____________________________

Date_________________________________________

Please send this application form to us at:

Yamoapowder.com, Yamoa for Children Scheme, 80 Godstow Road, Oxford, OX2 8NY, United Kingdom

Or fax it to us on +44 (0)1865 425668

We will confirm receipt of your application by email or telephone.