605.08E2 - Request to Prohibit a Student from Accessing Specific Instructional and Library Materials

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