FORM A Policy Ref. 606.02

FORM A Policy Ref. 606.02

 

ELKHORN PUBLIC SCHOOLS
REQUEST FOR SUBSTITUTION OF INSTRUCTIONAL MATERIAL

Directions: Complainant is to complete Section I and submit entire form to Building Principal.

SECTION I:

___________________________
Student’s Name

___________________________
Grade

___________________________
Building

___________________________
Teacher

 

Type of Material:

Book ___ Film ___ Filmstrip ___ Record ___ Other ___

 

___________________________
Author:

___________________________
Title

___________________________
Publisher:

Specific nature of complaint:

 

 

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

SECTION II:
(To be filled out by the Principal – sent to complainant)

In place of this resource/unit,

___________________________
Student’s Name

will be expected to:

 

 

___________________________
Principal’s Signature

___________________________
Date

Copy 1 – Building Principal
Copy 2 – Complainant
Copy 3 – Teacher
Copy 4 – Assistant Superintendent