Current Parents

Health Resources

2017-2018 Health Forms

The following forms are required by the State of Maryland. For a printable PDF version of this information, click here. Please contact School and Camp Nurse Patricia Ried, RN, PhD at 301-576-2814 if you have questions regarding the forms and what is required.

Mail or fax completed forms to Barrie at 13500 Layhill Road, Silver Spring, MD 20906, or 301-576-2805 (fax), attention Patricia Ried.

Deadlines

Barrie Camp - Health Forms are due at time of enrollment, or no later than June 1, 2017.

Barrie School Students - Health Forms are due no later than June 1, 2017.
Students and Campers will NOT be allowed to participate in any Barrie sponsored activities until these forms are completed and returned.

Required Forms for Camp and Summer Programs 2017

The following Health Forms are required for all campers participating in summer programs 2017. Forms for Campers must be received in the Camp Office by June 1, 2017 or at time of enrollment.

Emergency Information Form (Completed with enrollment agreement)

Part I Health Assessment Form (Completed by a parent/guardian)

Part II Health Assessment Form

Maryland Department of Health and Mental Hygiene Immunization Certificate

Other Forms

Medication Forms

Prescription Medications: Barrie School Authorization to Administer Medication Form - Complete this form if your student or camper requires prescription medication. This form can be completed once for the entire summer program or school year by a prescribing provider (physician, nurse practitioner, physician’s assistant, dentist, etc). A new form is required for each medication.

Over-The-Counter Medications: Barrie School Over-The-Counter Medication Authorization Form - To be completed by a prescribing provider and parents for the administration of over-the-counter medications as needed while at school or camp.

Asthma and Anaphylaxis

Asthma: Asthma Action Plan - An Asthma Action Plan is available for students diagnosed with asthma, to be completed by a prescribing provider and parents.

Anaphylaxis: Emergency Care of the Student with a Diagnosis of Anaphylaxis Form - required for students who have a severe life-threatening allergy and require an Epi-Pen. To be completed by a prescribing provider and the parents. Parents must supply Barrie two (2) Epi-pens of appropriate dosage and two (2) photos of the student.


Required Forms for New and Returning Barrie School Students 2017-18

Emergency Information Form (Completed with enrollment agreement)

Part I Health Assessment Form (Completed by a parent/guardian)

Other Forms

Medication Forms

Prescription Medications: Barrie School Authorization to Administer Medication Form - For students requiring prescription medication. This form can be completed once for the entire school year by a prescribing provider (physician, nurse practitioner, physician’s assistant, dentist, etc.). A new form is required for each medication.

Over-The-Counter Medications: Barrie School Over-The-Counter Medication Authorization Form -To be completed by a prescribing provider and the parents for the administration of over-the-counter medications as needed while at school.

Asthma and Anaphylaxis

Asthma: Asthma Action Plan - An Asthma Action Plan is available for students diagnosed with asthma, to be completed by a prescribing provider and parents.

Anaphylaxis: Emergency Care of the Student with a Diagnosis of Anaphylaxis Form - Required for students who have a severe life-threatening allergy and require an Epi-Pen. To be completed by a prescribing provider and the parents. Parents are responsible for supplying the school two (2) Epi-pens of appropriate dosage and two (2) photos of the student.

Overnight School Sponsored Activities Form - For students in grades 9-12 who require medications and are able to to self-administer on overnight trips, a Barrie School Self-Administration of Medication Authorization Form may be completed by a prescribing provider and the parents. Please note this is for OFF campus activities only. Students are not permitted to self-medicate at school except for Epi-Pens and emergency inhalers. The form is valid for the entire school year.

Forms required for Toddlers (18-24 months)

Part II Health Assessment Form - Completed by your prescribing provider completed no more than three months prior to the first day of school.

Maryland Department of Health and Mental Hygiene Immunization Certificate

Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate - for students living in specified ZIP code areas (see form).

Forms required for Primary Students (2 years-Kindergarten)

Part II Health Assessment Form - completed by your prescribing provider no more than twelve months prior to the first day of school.

NEW TO PRIMARY PROGRAM ONLY-- Maryland Department of Health and Mental Hygiene Immunization Certificate

Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate - for students living in specified ZIP code areas (see form).

New Students in Grades 1-12

Part II Health Evaluation Form - To be completed by your prescribing provider completed no more than twelve months prior to the first day of school. Maryland Department of Health and Mental Hygiene Immunization certificate

GRADE 1 ONLY-- Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate for students living in specified ZIP code areas (see form).

ALL Students in Grade 7

Maryland Department of Health and Mental Hygiene Immunization Certificate



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