Request to Limit Access Form

As a parent, you have the right to opt your child out of any instructional material in the library/classroom. To select titles/materials that your child should not check out from the library or have access to in a classroom, please complete this Request to Limit Access Form. You must include specific titles/materials for the restrictions to be implemented. Parents are asked to discuss any restrictions with their children prior to visiting the school library or participating in class.

Once school site staff receives the completed request to limit access form, your child’s library account will be updated in the library checkout system to reflect restricted titles and school administrators will be alerted of the request. If you have questions or need additional information, please reach out to your school principal.

One form must be completed for each child.

Parent Name*

First NameLast Name

Parent Email Address*

Phone Number*

Please enter a valid phone number.

School Name*

Confirm School Name*

Location Number*

Principal's Email

School Principal Email

example@example.com

Media Specialist's Email

Student Name*

First NameLast Name

Student ID *

Grade Level*

LIMIT ACCESS OPTIONS

Parents/guardians must choose from the following access options for their child:

Unlimited Access - This is the default access level and means that the student may have full access to check out materials from the library media center, including digital library materials, and unrestricted access to classroom materials.

Limited Access - This access level indicates the student may check out materials from the library media center, but there are specified books the student may not have access to or specific materials the student may not engage with during class. The parent(s)/guardian(s) must specify what specific titles/materials they do not wish the student to access and must provide the list of titles to the school. Generic topics or blanket subject areas, series name, theme, or other categoricals will not be considered. The request must have a high degree of specificity with regards to titles and/or names of specific materials.

No Access - This access level indicates the student is not permitted to access materials in the library media center, inlcuding digital library collections nor in the classroom environment. The parent(s)/guardian(s) must specify what specific titles/materials they do not wish the student to access and must provide the list of titles to the school. Generic topics or blanket subject areas, series name, theme, or other categoricals will not be considered. The request must have a high degree of specificity with regards to titles and/or names of specific materials.

Select One Opt-Out Option

Unlimited AccessLimited AccessNo Access

Adding Titles: To add a title, include the title and author's name. Then click on "Add Row" to add the title information to the list. Once you click on "Add Row" you will see the list of titles appear.

To add title/author, please click "Add Row" after each entry. Review all entries before submitting.*

By signing this form, I understand it is my parental responsibility to explain any restrictions to my child(ren) so they are aware before visiting the school library/classroom.