REQUEST TO PROHIBIT A STUDENT FROM CHECKING OUT SPECIFIC LIBRARY MATERIALS
Request to prohibit a student from checking out certain library 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 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 (filmstrip, motion picture, etc.)
Dated Signature
