5014 - Request to Show Movies/Videos


Date ___________________________________

Name of Teacher____________________________    Class _______________________

Name of Movie/Video _____________________________________Rating ____________

Date to be shown ______________________________________________


How does this movie/video relate to instructional objective?



Principal __________________________________________    Date _________________

"Please Note" Parents must be notified of the title and date of viewing in advance.

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Piute County School District
500 North Main - P.O. Box 69
Junction, Utah 84740-0069
Phone: (435)-577-2912 - Fax: (435)-577-2561
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Piute School District does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs. Please contact your school principal for further information.