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: