605.3E5-REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL AND LIBRARY MATERIALS

605.3E5-REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL AND LIBRARY MATERIALS

 

Code No.  605.3E5

 

REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL AND LIBRARY 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: 08/15/2023

Reviewed:

Revised: 

bbolsinger@edg… Tue, 09/19/2023 - 12:16