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 CHECKING OUT:
Author ___________________________________ Hardcover _____ Paperback_____ Other _____
Title _______________________________________________________________________________
Publisher (if known) __________________________________________________________________
Date of Publication ___________________________________________________________________
MULTIMEDIA MATERIAL TO PROHIBIT STUDENT FROM CHECKING OUT:
Title _______________________________________________________________________________
Producer (if known) ___________________________________________________________________
Type of material (filmstrip, motion picture, etc.) ____________________________________________
_______________________________ __________________________________________________
Date Signature
