Student Mask Exemption Form
To receive an exemption from wearing a mask or attending school in-person, this form must be COMPLETELY filled out and returned
to school PRIOR TO THE FIRST DAY OF ATTENDANCE WITHOUT A MASK.
Student’s Full Name
Student ID Number
Student Date of Birth
Home Address
School
Grade
Student Currently Has
Individualized Education Plan (IEP)
Section 504 Plan
Other specific school health orders
N/A
Parent Consent for Two Way Communication
I affirm that my student has been diagnosed with the medical condition(s) below. I consent to the release of related medical
documentation and authorize the medical provider identified below to discuss the condition with School District officials.
Parent/Guardian Name (print)
Date
Parent/Guardian Signature
Parent Consent to Mask Exemption
Well-fitting, appropriate face coverings over the nose and mouth are one of the best measures for preventing the transmission of
COVID-19 (please initial)
I understand that by not wearing a face mask, my child is at higher risk for exposure to and transmission of COVID-19.
I understand that, per California Department of Public Health (CDPH) guidance, persons exempted from wearing a face
covering due to a medical condition must wear a non-restrictive alternative, such as a face shield with a drape on the
bottom edge, as long as their condition permits.
Parent/Guardian Name (print)
Date
Parent/Guardian Signature
Medical Certification
As the student’s health care provider, I certify this student qualifies for a mask exemption according to the California Department
of Public Health and CDC guidelines. The student:
Is younger than 2 years of age
Has a diagnosable medical and/or mental health condition, or disability that prevents wearing a mask: (specify diagnosis):
__________________________________________________________________________________________________
Has a medical condition by which wearing a mask could obstruct breathing; are unconscious, incapacitated, or otherwise
unable to remove a mask without assistance
Is hearing impaired, or communicates with a person who is hearing impaired, where the ability to see the mouth is
essential for communication
Does NOT meet criteria for a mask exemption.
*This section must be completed for all students receiving an exemption.
I certify this student IS IS NOT capable of wearing a face shield with drape per CDPH guidelines.
This medical exemption is valid through the 2021-2022 academic year or until state or local laws or regulations, or public
health orders or recommendations change.
This medical exemption is temporary through: ____________________ or until state or local laws or regulations, or public
health orders or recommendations change.
Date
Address/Telephone
Name of Provider (Print)
Provider Signature
Medical License
