CPS Student Mask Requirement Opt-Out Form

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CONSENT FORM TO OPT-OUT FACE MASK REQUIREMENT

If a parent, guardian, legal custodian, or eligible student (must be at least 18 or otherwise authorized to provide consent) indicates that compliance with mask use is not possible due to medical, religious, or personal beliefs, they may request an exemption by completing this form.

If you have more than one (1) child in the district an Opt-Out Form will need be completed for each student, separately.

Parent/Guardian Information

Name

First Name *

Last Name *

Street Address *

City *

Zip Code *

Cell or Home Phone Number *

Email Address *

Student First Name *

Student Last Name *

Date of Birth *

YYYY

School *

Catalayah Elementary

Claremont Elementary

Claremore High School

Claremore Learning Center

Roosa Elementary

Westside Elementary

Will Rogers Jr. High

Please choose one of the following: *

Medical: I hereby certify the above-named child has a medical condition(s) that prevents compliance with the mask requirement.

Religious: I hereby certify the mask requirement conflicts with my religious beliefs.

Personal: I hereby certify I have personal objection to the mask requirement for the above-named child.

Signature

By typing your name below you are consenting to sign this document electronically.

Electronic Signature *

Submit

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