605.08E1 - Request to Prohibit a Student from Checking Out Specific Library Materials

Request 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