High-Risk Medical Exemption Form for Home Instruction

2021-2022 School Year

A student or an individual in his/her household who has a high-risk medical condition, as defined by the Centers for Disease Control (CDC) may request a medical exemption for home instruction during the 2021-2022 School Year.   In order to do this, a parent/guardian will need to submit a medical exemption form (attached) that their physician will need to fill out in order for a student to receive virtual instruction. This form is also available in the school nurse’s offices by request.  Please note that this home instruction will be held remotely and provide instruction for one (1) hour per day for elementary students and two (2) hours per day for secondary school students.

For clarification on the definition of a “High-Risk Individual,” please see below: 

High-Risk Individuals are those individuals who are at higher risk of severe illness as designated by the Centers for Disease Control (CDC), are physician-diagnosed with conditions such as:

  • asthma 
  • chronic lung disease 
  • compromised immune systems (including from smoking, cancer treatment, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, or use of corticosteroids or other immune weakening medications) 
  • diabetes 
  • severe heart disease (including heart failure, coronary artery disease, congenital heart disease, cardiomyopathies, and hypertension)
  • chronic kidney disease undergoing dialysis 
  • liver disease  
  • severe obesity 

To ensure your child has the optimal instructional program for his/her needs, please return the form below as soon as possible.  Please contact your child’s Principal should you have any questions. 


Natasha Walkowicz
Assistant Superintendent for Instruction

High-Risk Medical Exemption for Home Instruction Form