5014 - Request to Show Movies/Videos

Date ___________________________________

Name of Teacher____________________________    Class _______________________

Name of Movie/Video _____________________________________Rating ____________

Date to be shown ______________________________________________

Purpose 
____________________________________________________________________________

How does this movie/video relate to instructional objective?
____________________________________________________________________________

___________Approved  

___________Disapproved

Principal __________________________________________    Date _________________

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