Mask Requirement Exemption Form

At the October 11 Board of Education meeting, the Board voted to use the district’s COVID-19 dashboard data to determine mask requirements on a per building basis beginning Monday, Oct. 18.

The following criteria will be used to determine if/when masks are required on a per building basis:

The district will enact a temporary mask requirement for employees, students and visitors in any district building that reaches 3.0% or higher of active, positive cases of students/staff in that building. If enacted, it will remain in effect until the percent of active, positive cases lowers below 3.0%.

This district monitors the percentage of student/staff active, positive cases on a daily basis and will communicate with a building if/when this temporary mask requirement is put in effect.

To request an exemption from this requirement, should it be enacted, please complete the form below:

Mask Requirement Exemption Form

Student Name(Required)

First Last

Student Birth Date(Required)

School(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Email

Select the requested exemption:(Required)

MEDICAL EXEMPTION: The student named above qualifies because, in the opinion of an Iowa licensed physician (MD or DO), nurse practitioner, or physician assistant, such requirements are medically contraindicated as Masks would be injurious to the health and well-being of the person. If you have medical documentation in support of your request for exemption, please attach it in the next question. If no documentation is uploaded upon submission, the District reserves the right as legally authorized to ask for additional medical documentation to verify the person’s health condition and its impact on the Mask Requirement as well as to assess possible modifications to such requirements or other accommodations

RELIGIOUS EXEMPTION: The student named above qualifies because such requirements conflict with a genuine and sincere religious belief held by the person, which is in fact religious and not based merely on philosophical, scientific, moral, personal, or medical opposition to Masks.

BRAIN HEALTH/MENTAL HEALTH EXEMPTION: The student named above qualifies because such requirements have caused brain health/mental health concerns for the student, which has inhibited their ability to be successful at school.

OTHER EXEMPTION: Additional explanation required in next question.

Approval of OTHER exemption is determined at the discretion of the Superintendent or designee.

Acknowledgement(Required)

By clicking this acknowledgement, you further acknowledge and understand that failure to use Masks when required may increase the risk to yourself, your child, or others of contracting, carrying, and spreading COVID-19 infection. I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct.

I certify and acknowledge the above statement, and that I am the legal parent/guardian authorized to complete this form on behalf of my student listed above.