Request for Exemption for Wearing a Mask

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Complete this form to request approval for an exemption for wearing a mask in school. The Tri-County Public Health Order specifically states that exemptions may only be granted if a student is unable to medically tolerate a face covering. Following submission of this form, you will be notified if your request has been approved.
Documentation must include 1) Medical provider’s printed name, license number, address, phone number on the provider's letterhead (not prescription pad) 2) Signature of the medical provider and 3) Identification of the medical condition preventing the individual from wearing a mask and any recommended alternative to the mask.

Name of Person completing this form *

Your email address *

Student Name *

Grade *

School *

Does the student have a current plan in LPS? *

Health Care Action Plan (HCAP)

Section 504 Plan

Individualized Education Program (IEP)

None of the above

Required

I will provide documentation that meets all three criteria as listed in the introduction of this form above. Please send the appropriate medical documentation to jtempleton@lps.k12.co.us *

Yes

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