A Community Committed to Healthy Development

Three forms are REQUIRED for all infants, toddlers and primary students.   The medication form is additional and only if applicable.

Please note: A blood lead level certificate is required and is included in the Office of Child Care (OCC) Health Assessment I & II.

1. OCC Emergency Form

2. OCC Health Assessment I & II

3. Maryland Immunization Certificate

4. MDH Blood Lead Certificate Form

Required only if child takes medication

OCC Medication Form for 12 months - K 

Four forms are REQUIRED for new students in grades 1-5.  Medication forms are additional and only if applicable.

1. Emergency Contact Form

2. Health Assessment Part I 

3. Health Assessment Part II Physical exam must be completed by physician

4. Maryland Immunization Certificate
    

ADDITIONAL FORMS

If applicable,  see Medication, Asthma, and Anaphylaxis Forms section below.

1. Emergency Contact Form
2. Health Assessment Part I 
   The following additional form is REQUIRED for grade 3.
3. Health Assessment Part II (Physical Exam completed by Physician- Grade 3 only)

ADDITIONAL FORMS
If applicable,  see Medication, Asthma, and Anaphylaxis Forms section below.  Updated medical forms must be submitted each year, even if the information has not changed.

The following four forms are REQUIRED for new students in grades 6-12:

1. Emergency Contact Form

2. Health Assessment Part I

3. Health Assessment Part II (Physical exam must be completed by physician)

4. Movement Form

The following form is REQUIRED for grade 7:

1. Maryland Immunization Certificate

ADDITIONAL FORMS

Medication Forms: If applicable, see  Medication, Asthma, and Anaphylaxis Forms section below.

The following three forms are REQUIRED for grades 6-12:

1. Emergency Contact Form
2. Health Assessment Part I 
3. Movement Form
   The following form is REQUIRED for grades 6 & 9:
4. Health Assessment Part II (Physical Exam completed by Physician- Grade 6 & 9 only)
   
   The following form is REQUIRED for grade 7:
5. Maryland Immunization Certificate

ADDITIONAL FORMS

Medication Forms: If applicable, see  Medication, Asthma, and Anaphylaxis Forms section below.

• Authorization to Administer Medication
  Use this form for students requiring prescription medication or OTC medications (including topical creams, cough drops, and cough syrups, NOT Benadryl, Tylenol and Ibuprofen). 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.

  Authorization to Administer Medication  Form

• Stock Over-The-Counter (OTC) Medication

   To be completed by a prescribing provider and the parents for the administration of Benadryl, Tylenol, or Ibuprofen as needed while at school. This form must include specific dosages and requires a physician and parent signature.

  Medication forms must be completed for students who have been authorized to self-carry and self administer emergency medications (inhaler, epipens and diabetes medications). On the first day of school, the student will be required to check in with the school nurse to review medications and forms as well as verify expiration dates for the medications that they will be self-carrying while at school.

  Over-The-Counter Medication Authorization 

• Overnight School-Sponsored Activities

  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.

  Overnight School-Sponsored Activities Form

• Asthma

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

• Anaphylaxis
  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.
  
   Emergency Care of  Student with  Anaphylaxis

Students with diabetes:

Diabetes Medical Management Plan  

Student with seizure disorders:

Seizure action plan