Request to prohibit a student from accessing 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