605.3E4 IASB 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___________________________ Hardcover____ 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.) _________________________

Signature _______________________________________________ Dated ______________________________

 

Approved: 11/28/2022              Reviewed: 11/28/2022               Revised: 11/28/2022