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Universal Face Covering Exemption or Accommodation Request
Please complete a separate survey for each student for whom you are requesting an exemption or accommodation.
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* Indicates required question
Email
*
Your email
Name of person completing the survey
*
Your answer
Student name
*
Your answer
Building
*
Baresville Elementary
Manheim Elementary
Park Hills Elementary
West Manheim Elementary
Emory H Markle Middle School
South Western High School
Other:
Required
Does the student have an Individualized Education Program (IEP) or a 504 Plan?
*
Yes
No
Required
If the student does not have an IEP or 504 Plan, can you provide documentation of a medical or mental health condition or a disability?
*
Yes
No
Required
Please describe the medical or mental health condition or disability for which the exemption or accommodation is being requested.
*
Your answer
Please describe the exemption or accommodation you are requesting (full exemption, mask breaks, support to gradually increase mask time, use of a shield, etc.)
*
Your answer
If the child for whom you are requesting an exemption or accommodation wore a mask during the previous mandate with no accommodation other than mask breaks provided to all students, please describe how the student's condition has changed.
*
Your answer
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