Teacher:
Date:
Title
of Film:
Source
of Video / DVD
Note:
If the video is borrowed from the library, this form is not necessary, but you
will need to obtain parents’ permission.
_____Store Rental
_____Off-Air
Tape (following fair-use guidelines)
_____Privately
Owned (by teacher for classroom use only)
______Borrowed
from source other than high school library
Source
of loan:
Have
you previewed the video in its entirety? ________
Yes ________ No
Amount
of the movie/video to be shown (minutes):
Entire Film:
Film
contains (check all that apply):
Excerpt Contains (check all that apply):
___adult
language
___adult language
___sexuality
___sexuality
___violence
___violence
___illicit
drug or alcohol use
___illicit
drug or alcohol use
___none
of the above
___none of the above
___other
___other
Describe excerpt(s):
Briefly
describe the importance of this video to your specific curricular program and
your goals for learners:
Proposed
alternative assignment for students unable to obtain parent permission:
Proposed
date and time of viewing: Date(s):
Time(s)/
Block(s):
Committee
Comments:
________
Approved _________ Denied
Principal’s signature: Date: