Parent Rescind Opt Out Request

Parent Name(Required)

First Last

Parent Email(Required)

Parent Phone Number(Required)

Student Name(Required)

First Last

Student Email(Required)

Student ID Number(Required)

Student School Currently Attends(Required)

I would like to allow access to the following:(Required)

All library media materials in Dearborn Public Schools

A specific library media material item

All books on the “Book Challenge” list

Title of material to allow access(Required)

*MUST contain a specific book title you wish to restrict access to.

Author's name(Required)

*MUST contain an Author’s name to be sure the proper book is restricted.

I certify that I have legal authority to make this decision for the student listed.

Yes

(This is to ensure you are the legal guardian or parent with custody.)