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 ___________________________________________________
