Barrie School and Camp Health Forms

The following forms are required by the State of Maryland. Students and Campers will NOT be allowed to participate in any Barrie sponsored activities until these forms are completed and returned.

Instructions
Mail completed forms to Barrie at 13500 Layhill Road, Silver Spring, MD 20906, or fax to 301-576-2805, attention School Nurse.

Deadlines
  • Barrie Camp
    • ​​​​​​​Health Forms are due at time of enrollment, or no later than June 1, 2019.
  • Barrie School
    • ​​​​​​​All returning and newly enrolled students: Health Forms are due no later than June 1, 2019
    • Students enrolling after June 1: Health Forms are due no later than August 1, 2019.

Please contact School and Camp Nurse Kirstie Abernathy at 301-576-2814 if you have questions regarding the forms and what is required.


Required Forms for Camp and Summer Programs 2019

The following Health Forms are required for all campers participating in summer programs 2019. Forms for Campers must be received in the Camp Office by June 1, 2019 or at time of enrollment.

Five Mandatory Core Forms for All Campers

Toddler Stepping Stones Program

Medication Authorization Form for Campers in Pre-K thru Kindergarten (MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE)

Maryland State Department of Education Office of Child Care Health Inventory

Part I Health Assessment (OCC) 18 months - Primary 5

Part II Health Assessment (OCC) 18 months - Primary 5

Emergency Information Form (OCC) 18 months - Primary 5 

Includes:

  • Part I Health Assessment Form - to be completed by Parent or Guardian
  • Part II Child Health Assessment - to be completed ONLY by Physician/Nurse Practitioner
  • Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate - to be completed by Parent or Guardian, and Health Care Provider 

Medication, Asthma, and Anaphylaxis Forms (if needed)

Medication Forms

Prescription Medications: 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: 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.

Medication Authorization Form for Campers in Pre-K thru Kindergarten (MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE)

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 2019-20

In anticipation of the 2019-2020 school year, please be informed that health forms are due the following dates: 

  • All returning Barrie students and newly enrolled students- Health forms are due June 1st 
  • All students who are enrolling after June 1st- Health forms are due by August 1st 

All forms are located below on this web page. Forms can be provided directly to the Montessori Office (Kim), or Prep Office (Luticia). Forms may also be faxed to 301-576-2805. 

Completed forms that are turned in for 2019 Barrie Camp and/or summer programs will be used for the next school year. A second set of forms is not required for the 2019-2020 school year if your child is attending camp or a summer program at Barrie, however, additional health forms may be required in order to comply with the health form requirements as specified by student’s grade level. See the Checklist by Grade for more details.

Students will not be able to start school without all the required forms completed and submitted in a timely manner. Please contact me directly with any questions or concerns. 

Thank you, 

Kirstie Abernathy MS RN CPN 
301-576-2814

Emergency and Health Assessment Forms

Part I Health Assessment (OCC) 18 months - Primary 5

Emergency Information Form (OCC) 18 months - Primary 5 

Emergency Information Form (Completed with enrollment agreement) Grade 1-12

Part I Health Assessment Form (Completed by a parent/guardian) Grade 1-12

Medication, Asthma, and Anaphylaxis Forms

Medication Forms

Medication Policy

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.

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.

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.

Health Forms for all Barrie Students in 18m-Kindergarten

Medication Authorization Form for Students in Pre-K thru Kindergarten (MARYLAND STATE DEPARTMENT OF EDUCATION OFFICE OF CHILD CARE)

Required Forms for Toddlers (18-24 months)

Maryland State Department of Education Office of Child Care Health Inventory

Part I Health Assessment (OCC) 18 months - Primary 5

Part II Health Assessment (OCC) 18 months - Primary 5

Emergency Information Form (OCC) 18 months - Primary 5 

Includes:

  • Part I Health Assessment Form - to be completed by Parent or Guardian
  • Part II Child Health Assessment - to be completed ONLY by Physician/Nurse Practitioner
  • Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate - to be completed by Parent or Guardian, and Health Care Provider 

Required Forms for Primary Students (3 years-Kindergarten)

Maryland State Department of Education Office of Child Care Health Inventory

Includes:

  • Part I Health Assessment Form - to be completed by Parent or Guardian
  • Part II Child Health Assessment - to be completed ONLY by Physician/Nurse Practitioner
  • Maryland Department of Health and Mental Hygiene Blood Lead Testing Certificate - to be completed by Parent or Guardian, and Health Care Provider

New Students in Grades 1-12

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

Maryland Department of Health and Mental Hygiene Immunization Certificate

ALL Students in Grade 7