605.03E5 - Request to Prohibit a Student from Accessing Specific Instructional and Library 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 OTHER PRINTED MATERIAL IF APPLICABLE:

Author _______________________________________________________Hardcover___ Paperback___ Other___

Title_____________________________________________________

Publisher (if known)_________________________________________

Date of Publication___________________________

 

MULTIMEDIA MATERIAL IF APPLICABLE:

Title_____________________________________________________
Producer (if known)_______________________________________________

Type of material (filmstrip, motion picture, etc.)__________________________

 

Dated ____________________________  Signature_________________________________________________________