Code No. 605.3E4
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, onlione resource, motion picture, etc.) _____________________________
Signature ________________________________________________
Date: ___________
Approved 7-25-2022 Reviewed Revised