Code No. 605.3E5
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.) ________________________________________________
_______________________________ ____________________________________________________
Date Signature
