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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:
Name:
Date:
Address:
Name of Student:
School:
Grade:
Requestor's relationship to students (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.):
Requestor's Signature:
Date:
Adopted: 8/23
Reviewed: 2/24
Related Policy: 602.28
IASB Reference: 605.03-E(5)