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
