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
Approved: 7/17/2023, 11/18/2024
Reviewed: 10/21/2024
Revised: 10/21/2024
