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AGASD Mask Exemption Doctor Form (FINAL) 9/3/21, 7:28 PM
ALBERT GALLATIN AREA SCHOOL DISTRICT
CERTIFICATION OF HEALTH CARE PRACTITIONER
FACE COVERING EXEMPTION FORM
Student Name_____________________________
To Health Care Practitioner:
The Parent/Guardian of the Albert Gallatin Area School District Student referenced above
has requested a medical exemption from wearing a face covering while attending school.
As the Student's Health Care Provider, you are asked to provide the following
information:
Health Care Practitioner's name: (Print)________________________________________
Health Care Practitioner's Title/ Certiļ¬cation/Licensure:___________________________
Health Care Practitioner's business address:_____________________________________
Type of practice/medical specialty:_________________________________________
Telephone: ( )______________(Fax)___________________
Email address:________________________________________
1. Based on your professional knowledge, experience, and knowledge of this Student, does
the Student currently suffer from a medical condition, mental health condition or a disability that
would be exacerbated by being required to wear a face covering (other than a face shield)
indoors at school?
Yes:_______ No:__________
If yes, please explain_______________________________________________________
1.A. If yes, would this medical condition, mental health condition or disability preclude the
Student from safely wearing a face shield indoors in school?
Yes:_________ No:__________
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AGASD Mask Exemption Doctor Form (FINAL) 9/3/21, 7:28 PM
2. Based on your professional knowledge, experience, and knowledge of this Student,
would a requirement that the Student wear a face covering (other than a face shield) indoors at
school
cause the Student to develop a medical condition, mental health condition or a disability?
Yes_____________ No_______________
If yes, please explain____________________________________________________________
2.A. If yes, would this also preclude the Student from safely wearing a face shield indoors in
school?
Yes_____________ No_______________
3. Based on your professional knowledge, experience, and knowledge of this Student, is the
Student hearing-impaired or suffering from another disability where the ability to have his/her
mouth seen, is essential for communication, such that being required to wear a face covering
(other than a face shield) indoors at school would exacerbate the Student's hearing-impairment or
other disability?
Yes____________ No______________
If yes, please explain___________________________________
3.A. If yes, would this preclude the Student from safely wearing a face shield indoors in
school?
Yes______ No_______
4. Please provide any additional information which, in your professional opinion, is relevant
to these issues.
Signature of Health Care Provider: _______________________________________
Date: ____________________
