EDUCATIONAL PROGRAM
Series 600
Policy Title: Request to Prohibit A Student From Accessing Specific Instructional and Media Center Materials
Code No. 630E4
REQUEST TO PROHIBIT A STUDENT FROM ACCESSING
SPECIFIC INSTRUCTIONAL AND MEDIA CENTER MATERIALS
Request to prohibit a student from accessing certain instructional and media center materials to be submitted to the superintendent. 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
Date of Adoption/Review/Revision:
November 2022
August 2023
