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 _____
Publisher (if known ) _______________________________________________________________________
MULTIMEDIA OR OTHER PRINTED MATERIAL TO PROHIBIT STUDENT FROM ACCESSING:
Title _______________________________________________________________________________________________
Producer (if known) ___________________________________________________________________________________
Type of material (filmstrip, motion picture, etc.) ______________________________________________________________
________________________________ _______________________________________________________________
Dated Signature
*Adopted: 09/25/23