605.03E5
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:
