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:
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Hardcover |
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Paperback |
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Other |
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Title |
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Publisher (if known) |
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Date of Publication |
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Multimedia Material to Prohibit Student from Checking Out:
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Title |
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Producer (if known) |
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Type of material (website, online resource, filmstrip, motion picture, etc.) |
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Dated Signature
