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