Name:
|
Building:
|
User is: Employee Student |
| |
Today's Date
(mm/dd/yyyy) |
| I request the temporary adjustment of the district’s Internet blocking/filtering to allow access to the following website for bona fide research or other lawful purposes: |
Website address:
|
| |
I intend to access the website for the following research or lawful purpose:
|
| I request the filtering adjustment for the following time period: |
Start Date
(mm/dd/yyyy) |
End Date
(mm/dd/yyyy) |
| I acknowledge that failure to comply with Board policy or inappropriate use of the district’s Internet, computers or network resources may result in action including, but not limited to, usage restrictions, loss of access privileges, disciplinary action and/or referral to legal authorities. I hereby release the district and its Board members, employees and agents from any claims and damages arising from my use of, or inability to use, the district’s Internet, computers and network resources. |
| User's Signature: |
| Signature of Sponsoring Teacher/Administrator: |
| **For students only, parent/guardian permission is required prior to temporary adjustment of blocking/filtering. |
| I give permission for my child to have temporary access to the website listed above for bona fide research or other lawful purposes. I will hold harmless the district, its Board members, employees and agents for any harm caused by materials obtained via the district’s Internet, computers or network resources. I accept full responsibility for supervision if and when my child’s use is not in a school setting. |
| Parent/Guardian Signature: |
| |
Date of Request
(mm/dd/yyyy) |
| **Submit this form to the building principal. Decisions to deny access may be appealed to the Superintendent or designee for expedited review. |
***************************************************************************************************************************************** For District Use Only Temporary Access is: Approved: Denied: Signature of Building Principal/Administrator: Date of approval: Appeal Submitted Date: Temporary Access is: Approved: Denied: Signature of Superintendent or designee: Date of approval: |
| |
| |
| |
| |
| |
| |
| |
| |