605.03E(4) - Request to Prohibit A Student from Accessing Specific Library Materials
605.03E(4) - Request to Prohibit A Student from Accessing Specific Library MaterialsRequest to prohibit a student from checking out certain library 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.) __________________________________________________________
_______________________________________________ _____________________________________________
Dated Signature
Approved: 11/21/2022, 7/17/2023, 11/18/2024
Reviewed: 10/21/2024
Revised: 10/21/2024