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_________________________________________________________
