605.3E5 Request to Prohibit a Student from Accessing Specific Instructional and Library Materials (Aug 2023)

REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL AND LIBRARY MATERIALS

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.) _____________________________________________

 

 _______________________________________       ___________________________________________

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