Teays Valley Mask Medical Exemption Form

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All students in grades K-8 are required to wear facial coverings during the school day. Further, all K-12 students are required to wear masks on the bus. A face shield may be used under certain circumstances as determined by the Superintendent.

Parents/Guardians can use this form to request a medical exemption from the District's facial covering policy. The Superintendent may grant or deny a request for a medical exemption from the District's facial covering policy. Further, the Superintendent (or his/her designee) may request further documentation justifying the medical exemption. These requests will be reviewed and a school nurse or their designee will follow up to let you know if the request has been approved or denied. Please allow 2-3 days for a response.

Email *

Student First Name

Student Last Name

Parent/Guardian

Phone Number

Building

Ashville

Scioto

South Bloomfield

Walnut

East

West

High School

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My child requests an exemption from the District's facial covering policy:

My child has a documented health or developmental condition such that he/she cannot wear a facemask. I'm requesting a medical exemption so they can wear a face shield.

My child has a documented health or developmental condition such that he/she cannot wear a face mask or face shield. I'm requesting a medical exemption so that my child does not have to wear a face mask or face shield.

My child has a documented religious exemption that does not permit him/her to wear a face mask or face shield.

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By checking this box, I acknowledge that I will provide the District with documentation verifying the medical reason for this request.

Yes

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I understand by checking this box that the Superintendent may grant or deny a request for an exemption from the District's facial covering policy. I understand that someone will follow up with me to let me know if my request has been approved or denied. This response may take 2-3 days.

Yes

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