FCA - Student COVID-19 Mask Medical Exemption Form 2021-2022
By signing below, you confirm that your student is unable to wear a face covering (mask), as required by Firestone Charter Academy due to a medical reason that affects the student, as described below.  By completing this form, you are requesting that your student by exempted from the mask requirement for the 2021-2022 school year.
**If you are completing an exemption for multiple students, you must complete s different form for each child.**
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Email *
Date *
MM
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DD
/
YYYY
Student Name *
Student Grade Level *
Student's Teacher (homeroom for 5th-8th) *
Parent Name(s) *
I affirm that I am the parent or legal guardian of the student, and that the medical reason described below affects my student's ability to wear a mask. *
Please list the medical reason for your student to be exempted from the mask requirement for the 2021-2022 school year. *
I understand that because my student will be exempted from the mask requirement, my student is at an increased likelihood of being quarantined in the event of an exposure to COVID-19 at school. *
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