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
