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
