605.03-E5 Objection to Instructional and Library Materials - Request to Prohibit a Student from Accessing Specific Instructional Material

605.03-E(5): Objection to Instructional and Library Materials - Request to Prohibit a Student from Accessing Specific Instructional Material

Request to prohibit a student from checking out certain instructional materials to be submitted to the building administrator. 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.)__________________________________

 

__________________ _______________________________________________

Dated Signature

 

Approved: 10/2/23

Reviewed: 10/2/23

Revised: 10/2/23