Face Mask Exemption Form

Name*
First Last
S Number*
Phone*
Email*
Campus Location(s) to be Accessed*
- Fort Morgan Campus
- Bennett Center
- Burlington Center
- Limon Center
- Wray Center
Select all that apply.
Reason for Requesting an Exemption (Provide information about why you cannot medically tolerate a face mask.)*
If your request is approved, what additional safety measures will you take to further mitigate the risk in the absence of a face mask? (Examples: 1. I can wear a face shield instead of a mask. 2. I will attend my courses remotely instead of in-person. 3. I will maintain extended social distancing and will wear a mask or face shield as I travel through common areas.)*
Medical documentation from an appropriate medical provider specifying the diagnosis. Your submitted documentation will be considered for approval of your request.*
Drop files here or
Max. file size: 50 MB.
If preferred, documentation can be submitted in-person to Scott Scholes or Julie Beydler.
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