Consent Form to Opt-Out of Face Mask Requirement By Deer Creek Public Schools
If a parent/legal guardian, eligible student, or Deer Creek employee/volunteer indicates that compliance with the mask requirement is not possible due to medical, religious, or a strong personal reason, completion of the following information is required in order to request an exemption.
If there is more than one person within a household, a separate consent form will need to be completed for each individual.
School Site or Department
4th & 5th Grade Center
Volunteer at more than one school site
Classification of individual requesting exemption
Deer Creek Employee
LAST NAME of individual (student, staff, sub, or volunteer) receiving exemption
FIRST NAME of individual receiving exemption
Name of Parent/Legal Guardian (if student under 18)
Home address (including street, city, state, zip code)
Phone number (including area code)
Select type of exemption
MEDICAL CONTRADICTION: I hereby certify that a medical condition and/or restriction(s) prevents the named student/employee from complying with the mask requirement.
RELIGIOUS OBJECTION: I hereby certify that the mask requirement is contrary to the teachings of the named student's/employee's religion.
PERSONAL OBJECTION: I hereby certify that I opt-out as an employee or my child from the wearing of a mask for strong personal reasons.
I am electing for my student (parent/guardian) or myself (employee or other) to opt-out of the mask requirement.
By signing below (full first and last name), I attest that: (1) I have signed this form freely and voluntarily, and I am legally authorized to make decisions for the listed employee or student. (2) I understand and agree that nothing herein shall relieve the parent, guardian, employee, or student named from any liability associated with not wearing a face covering. (3) I agree on behalf of myself and/or the student to hereby release the school and Deer Creek Public Schools from any and all liability associated with not wearing a face covering. (4) I will notify the school (parents/guardians) or my supervisor (employees) in writing if I choose to revoke my consent.
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