Archbishop Bergan Catholic School Student Attendance Medical Exemption Form for the  2020-2021 academic school year
This form is only to be completed by families with one family member living in the domicile that has an underlying Medical condition.  Please complete the following questions in order for your student's attendance to be considered to be exempt for the 2020-2021 school year.  This will be reviewed by administration and you will receive an email or phone call back verifying the final decision on your student's attendance expectations.  
***If your student(s) is approved for a Medical Exemption from attending school daily, your student is deemed ineligible to participate or attend any extracurricular activities sponsored by the school.
Sign in to Google to save your progress. Learn more
Email *
1) Name of the parent/guardian completing this form. *
2) Please list all of your Grades PreK-12 students that you are requesting to NOT be attending school in person this school year. *
3) Does one family members living in the domicile have an underlying Medical condition that can not be compromised with possible COVID-19 exposure? *
4) Please explain whom within the family has the above mentioned Medically diagnosed condition. *
5) What is the underlying Medical condition listed for the individual above that you are concerned about? *
5) What are the Medical concerns you have with your student attending school this school year knowing that safety precautions are being implemented by the school? *
6) Would you consider sending your student back to school for in person instruction during the 2020-2021 school year? *
7) If you would consider sending your student to back to school for in person instruction, when would you plan on sending them back to school? *
8) What will have to happen or take place for you to feel safe enough to consider sending your student back to school for in person instruction during the 2020-2021 school year? *
9) Do you have any additional comments, questions or concerns that you would like to share with the Archbishop Bergan Catholic School administration?  Please list these below.
10) Please list the most current email and phone number that school administration can use to reach you. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Archbishop Bergan Catholic School. Report Abuse
Google Forms