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.) ____________________________________________
______________________________ ____________________________________________
Date Signature