This form must be completed before any video is used.

Title of Video _________________________________________

School owned (circle)   yes    no  If no, name source ________________________________

Rating ______

Objective (Standard Course of Study #, blue print #) __________________________________

______________________________________________________________________________

How does this video support the curriculum? _________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Have you viewed this video?   yes     no   (Circle one.)

Are you showing the entire movie?     yes      no    (Circle one.)

Anticipated date(s) to be shown: ___________________________________________________

Is this video free of obscenities, profanity, nudity and excessive violence?

yes      no      (Circle one.)

__________________________________                    Approved

Teacher Signature                date                                      Denied

                                                                                       Conference Requested

__________________________________                           

Principal Signature                date