605.3-E(5) Request to Prohibit a Student from Accessing Specific Instructional Materials

REQUEST TO PROHIBT 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                                                                                            Zip Code                              Telephone                                        

Name of affected student                                                                                                                                                                           

Requester’s Relationship to Student (must be parent/legal guardian)

BOOK OR OTHERE PRINGED 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