605.3E4 Request to Prohibit a Student From Checking Out Specific Library Materials

 

Code No.  605.3E4

REQUEST TO PROHIBIT A STUDENT FROM CHECKING OUT SPECIFIC LIBRARY MATERIALS

This request shall be submitted to the superintendent.  Please complete one form per student.

Request made by:                                                                Date:________________________

Name:________________________________________________________________________________

Address:______________________________________________________________________________

City:____________________________ State:___________ Zip Code:_______________

Telephone:_______________________

Name of Affected Student:________________________________________________________________

Requester’s Relationship to Student (must be parent/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 (website, online resource,

filmstrip, motion picture etc.) _______________________________________________________________

_________________________ __________________________________________________

Dated Signature