605.3E4 REQUEST TO PROHIBIT A STUDENT FROM CHECKING OUT SPECIFIC LIBRARY MATERIALS
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 Number:
Name of affected student:
Requester’s Relationship to Student (must be parent/legal guardian):
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:
Signature Date