Request to prohibit a student from checking out certain instructional materials to be submitted to the superintendent. Please complete one form per student.
REQUEST INITIATED BY DATE ___________
Name___________________________________________________________________
Address_________________________________________________________________
City/State ____________________________Zip Code__________________ Telephone_____________
Name of affected Student__________________________________________________
Requester’s Relationship to Student (must be parent/legal guardian)__________________________________________________
BOOK OR OTHER PRINTED MATERIAL TO PROHIBIT STUDENT FROM ACCESSING:
Author ______________________________ Hardcover __________
Paperback ________________ Other ______________
Title _______________________________________________________
Publisher (if known) __________________________________________
Date of Publication ________________________
MULTIMEDIA MATERIAL TO PROHIBIT STUDENT FROM ACCESSING:
Title _______________________________________________________
Producer (if known) ___________________________________________
Type of material (filmstrip, motion picture, etc.) ______________________
_____________________________________________ __________________
Signature Date