REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL 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
Cross Reference:
213 Public Participation in Board Meetings
Approved: 08/14/2023 Reviewed: ___________ Revised: ________