AUTHORIZATION TO RELEASE INFORMATION TO EMPLOYMENT RESOURCES INCORPORATED

THE GLADYS H. OBERLE SCHOOL
404 Willis Street
Fredericksburg, VA 22401
540.372.6710 (Office) 540.373.1791 (Fax)

Student’s Full, Legal Name

DOB

Date

SS#

Address

I give my permission for Employment Resources Incorporated and The Gladys H. Oberle School to obtain and exchange specific information or reports from the following: (Check all that apply and add any others that may apply)

Local Education Agency (School) Mental Health Provider Previous Private Placements Court Services Medical Doctor Department of Social Services

Other

These records or reports include information that may affect my attendance and/or performance at The Gladys H. Oberle School including academic, behavioral, discipline and attendance information from public and private placements; Juvenile records from the Court Service Unit that includes juvenile offenses, mental health, substance abuse and other counseling, probation rules and other court-ordered rules; Health records that include current physical examination, immunization records and physical/mental health status, current medications and restrictions as they relate to my ability to successfully participate in school- and community-based activities; and (list any other information that may apply)

I am aware that my records are protected under the Federal Confidentiality Regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I hereby release ERI or its representatives from all legal responsibilities or liability that may arise from this act. I understand that this consent may be revoked by me at any time by providing written notice to ERI or its representative. I further understand that information released prior to any revocation cannot be retrieved nor can ERI or its representatives be held responsible for such an act. In any event, this consent expires automatically when the above student is no longer enrolled in The Gladys H. Oberle School or July 31, 2022, whichever comes first.

Date

Student Signature

Clear

Parent/Guardian Signature

Clear

Employment Resources Incorporated Representative Signature

Clear