Please note that you must update this information as soon as ANY changes occur!

List all medical conditions, allergies (include substance abuse, physican and mental health conditions: 

Current Medication Information:

*Please note, per State law, a copy of your child’s immunization record and verification that a physical has been done must be provided to Oberle prior to enrollment.

*If ERI personnel are to assist with administration of medication(s) during school, the student’s physician and parent/guardian must complete and turn in the Request for Medication During School Hours Form.

, residing in the Commonwealth of Virginia and the parent/guardian of

who resides with me, do hereby authorize and empower the staff of Employment Resources Incorporated or school chaperones to consent to administer any X-Ray examinations, anesthetic, medical, or surgical diagnosis or treatment, and hospital care to be rendered to this minor child under the general or special supervision and on the advice of a duly licensed physician or surgeon. Further, I do hereby authorize staff to contact appropriate personnel, refer and/or transport my child to an emergency service worker should he or she be deemed a danger to himself or others. Further, I do hereby authorize staff to contact appropriate personnel for a possible screening should my child appear to be under the influence of alcohol or drugs. This authorization is in effect for all school functions including transition training experience, field trips and recreational activities during the 2021-2022 school year that begins June 1, 2021 and ends July 31, 2022.