605.3E4 - Request to Prohibit a Student From Checking Out Specific Library Materials

This request shall be submitted to the superintendent.  Please complete one form per student.

Request made by:                                                                      Date:                           

Name:                                                             

Address:                                                          

City:                                                                             State:                            Zip Code:                    

Telephone:                                                       

Name of Affected Student:                                                                    

Requester’s Relationship to Student (must be parent/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 (website, online resource, filmstrip, motion picture, etc.)

 

                                                                                                                                                           
Dated                                                               Signature