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.) _____________________________________________
_______________________________________ ___________________________________________
Dated Signature
