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
