Name of Video: __________________________________
Requested date to be shown: _______________________
Requested time of day: ____________________________
Relationship to Curriculum:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
______________________________
______________
Teacher's Signature
Date
Signature of other team members or grade level teachers who will be viewing the video:
| ____________________ | ____________________ |
| ____________________ | ____________________ |
| ____________________ | ____________________ |
| ____________________ | ____________________ |
| ____________________ | ____________________ |
Request approval by:
| ________________________________
Librarian |
____________________
Date |
| ________________________________
Administration |
____________________
Date |
* This form must be completed at least
one week prior to showing of the video.