Please submit this form to request accommodation for face mask exemption accommodation due to a medical condition and/or disability. This form must be submitted in addition to documentation from your medical provider providing information on why a face mask exemption is necessary. This documentation should be mailed, emailed, or faxed to the Director of Disability Support Services. Please contact firstname.lastname@example.org with any questions or concerns. This form should only be completed by current students and/ or admitted students who have deposited. This form is separate from the disability disclosure and request form for academic accommodations. Mask exemption accommodations will be considered carefully and on a case-by-case basis.
A note about confidentiality: Please note that this form will be submitted electronically and sent via email. Confidentiality of its contents may not be guaranteed. If you would prefer to complete paper copies of this form, please contact email@example.com for electronic or hard copy versions.
*Disability includes a physical or mental impairment that substantially limits one or more major life activities. Major life activities include such things as caring for oneself, performing manual tasks, walking, sitting, standing, lifting, reaching, seeing, hearing, breathing, learning, and working.
All fields marked with asterisk (*) are required.