605.3E5 Request to Prohibit a Student From Accessing Specific Instructional Materials

605.3E5 Request to Prohibit a Student From Accessing Specific Instructional Materials

REQUEST TO PROHIBIT A STUDENT FROM ACCESSING 

SPECIFIC INSTRUCTIONAL 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_____________________________  ZipCode _________  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 : 12-20-23                  Reviewed:                         Revised: 

awoods@gt.rati… Tue, 01/02/2024 - 13:03