BELLINGHAM PUBLIC SCHOOLS
Bellingham, Washington
2311F
DATE: ___________
TITLE: ________________________________________________________________________
AUTHOR/PRODUCER (if known): __________________________________________________
TYPE OF MATERIAL (e.g., assigned text, supplemental reading material, library material, etc.): __________
NAME OF REQUESTER: _____________________________ TELEPHONE: ______________
ADDRESS: ____________________________________________________________________
SCHOOL STUDENT ATTENDS: ________________________ GRADE LEVEL: _________
REQUESTER REPRESENTS: Parent: ____ Guardian/Custodian:____Other (please specify): _____
What specific passages or aspects of the material do you object to? Please include page numbers, quotes, and/or excerpts, if possible. ________________________________________________
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What do you feel might be the result of reading/viewing this material? _____________________
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For what age group would you recommend this material? ______________________________
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Is there anything of value in this material? ___________________________________________
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Did you read/view the entire content? ______ What parts? ________________________________
What do you believe is the theme of this material? _____________________________________
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What would you like your school to do about this material? (e.g., do not assign it to my child; withdraw it from all students as well as from my child; send it back to the Instructional Material Committee (IMC) for additional evaluation) _____________________________________________________________________
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In its place, what material would you recommend on the subject? _________________________
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Signature of Requester ____________________________
Please return this form to the Superintendent's Office at 1306 Dupont Street
Return to Table of Contents June 26, 2003