Code No. 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___________
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 known) _________________________________________________________
Date of Publication __________________________________________________________
MULTIMEDIA MATERIAL TO PROHIBIT STUDENT FROM CHECKING OUT:
Title _____________________________________________________________________
Producer (if known) _________________________________________________________
Type of material (filmstrip, motion picture, etc.) ____________________________________
_______________________________ ________________________________
Dated Signature
Approved: 6/14/23, Reviewed, Revised:
Grinnell-Newburg School District, Grinnell, IA