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.) ______________________________________________

 

Dated ____________     Signature  ___________________________________________________