Reconsideration of Instructional Materials Request

	REQUEST For RECONSIDERATION OF INSTRUCTIONAL MATERIALS

1.	List of Loudoun County Public Schools* Select school using the material - a required field

2.	Please check type of material:* Must select one choice
	Please check type of material:* Must select one choiceBook DVD Kit Pamphlet Periodical Video Cassette Other, please specify

Product Information*
(Please complete fully)
Enter at least 3 responses and no more than 3 responses.

Title:
Author:
Publisher or Producer:

Requestor Contact Information*
(Person making request must be the parent or legal guardian of an LCPS student - must include all requested information)
Enter at least 6 responses and no more than 6 responses.

Request Initiated by:
Telephone:
Address:
City:
State:
Zip Code:

5.	Email Address of Requestor (if available)

Reconsideration of Instructional Materials Request ver. 4