Basic Classroom Permission Slip

(Last Updated On: October 21, 2014)

[Your School]
Movie/Video Permission Form

Request Date:__________________________________________

Teacher Name:_________________________________________

Name of Movie/Video:____________________________________

Rating on Movie/Video:___________________________________

Reason for showing the Movie/Video:_________________________
___________________________________________________
___________________________________________________
___________________________________________________

Date of viewing:_________________________________________

Teacher Signature:_______________________________________

Student Name:__________________________________________

Parent/Guardian Approval:_________________________________

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