Cell Phone/Electronic Device Exception Request Form

Request Submitted by

Parent/Guardian Name:

First NameLast Name

Staff Member Name

First NameLast Name

Your Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Your Email Address

example@example.com

Student Name

First NameLast Name

Student ID Number

School Student Attends

Student's Grade Level

Student's Homeroom/Advisory Teacher

Type a question

Please describe the reason for this request

Upload Supporting Documentation

Reference: documentation required by basis for request

Basis for Request: What's Needed

Medical need: Signed statement from a licensed physician or healthcare provider
IEP: No separate upload required if already documented in the IEP (staff will verify)
Section 504 Plan: No separate upload required if already documented in the Plan (staff will verify)
Language-access support: Written confirmation from EL staff
Other accommodation: Supporting documentation as applicable (e.g., counselor recommendation)
Verified ongoing emergency: Written explanation of the specific safety circumstance

Exceptions tied to an IEP or 504 Plan remain in effect for the duration of that plan and are reviewed at each plan review. Medical and other exceptions are approved for a specified period, not to exceed one school year, and must be renewed annually or when circumstances change.

Requested scope of device access

If applicable, list specific times/locations requested

Device type(s)

Other

By signing here, I certify that the information provided above is accurate to the best of my knowledge, and I understand that approved exceptions are subject to the conditions established by school administration.