605.3E4 -- Request to Prohibit a Student from Checking Out Specific Library Materials

REQUEST TO PROHIBIT A STUDENT FROM CHECKING OUT SPECIFIC LIBRARY MATERIALS

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_____________________Harcover__________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

 

Date of Review:
November 14, 2022