REQUEST TO PROHIBIT 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 OTHER PRINTED 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_________________________________________________________
Approved 9/18/23 Reviewed Revised