1. Please Note:
      2. NOTES

Form 167-1

 

                                
  

10307-99 St, Peace River, AB T8S 1K1
Phone: 780-624-3956 Fax: 780-624-1154
 

Face Mask Exemption Request Form

 

Form -1

Mask Exemption Request Form


  Please review the HFCRD Non-Medical Face Mask Protocol. Complete all sections of this form and return it to the Office at your school/site.

Student/Staff Name: _________________________ School: _____________________ Grade: ____

Mask Exemptions are evaluated based on health related or complex needs of the individual. Please describe the need that you are requesting this Mask Exemption for and if health-related provide a copy of a medical note.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________



Please Note:

■   When this completed form is received, administration will contact you to discuss your request.

Parent/Guardian/Staff Name: ____________________________________________________________

Contact Numbers: ____________________________________________________________________

Parent/Guardian/Staff Signature: ______________________________________________________________

 

For school use only:

Date: ____________________________ Approved: [ ] Denied: [ ]

Comments: ____________________________________________________________________________________________

______________________________________________________________________________________________________

Signature of Administration: _________________________________________________

The information on this form is being collected in accordance with the Freedom of Information and Protection of Privacy Act, under the authority of The Education Act, and Holy Family Catholic Regional Division policies and procedures. If you have any questions about the collection, use, or disclosure of this information, please contact the Holy Family Catholic Regional Division FOIP Coordinator at 780-624-3956.

 



NOTES

·   Mask Exemptions will only be considered based on health related or complex needs of an individual.
·   Mask Exemptions will not be granted based on:
o   Personal preference
·   School-based decision on mask exemptions may be appealed in writing as long as they are based on health related or complex needs of an individual.
·   Central Administration will only consider appeals based on health related or complex needs of an individual.

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   __________________  
Form 167-1  August 2020
 
 
   __________________  
Grande Prairie Public School Division  November 2019
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