Student Face Covering - Exemption Verification
If your child has a medical or mental health condition or disability that precludes the wearing of a face covering while at school, and you are requesting an exemption based on the Pennsylvania Department of Health Secretarial Order that was issued on August 31, 2021, you must submit this form to the school nurse.
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SECTION A. To be completed by the child’s parent/guardian.
Full Name of Student *
Student ID#
School Building *
Grade *
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