Request for re-evaluation of printed or multimedia material to be submitted to the superintendent.
REVIEW 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 CHECKING OUT:
Author ______________________ Hardcover ____ Paperback ______ Other ______
Title ____________________________________________________________________
Publisher (if know) _________________________________________________________
Date of Publication _________________________________________________________
MULTIMEDIA MATERIAL TO PROHIBIT STUDENT FROM CHECKING OUT:
Title _____________________________________________________________________
Producer (if know) __________________________________________________________
Type of material (filmstrip, motion picture, etc.) ____________________________________
__________________________ _______________________________________
Dated Signature
