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LUGOFF-ELGIN
HIGH SCHOOL
TEACHER
REQUEST TO USE NON-SCHOOL
VIDEOS
TEACHER__________________________
DATE___________
CLASS(ES)
VIDEO TO BE SHOWN TO
DATE
VIDEO TO BE SHOWN TO CLASS(ES)___________________________________
NAME OF VIDEO____________________________________
RATING
OF VIDEO__________________________________
OWNER
OF VIDEO___________________________________
This
video will be used as part of my instructional program and will be shown
only to my class. A legitimate
copy will be used. It will not
be shown for entertainment purposes.
OBJECTIVE
BEING TAUGHT
______________________________________________________________________
______________________________________________________________________
REASON
FOR USING THE VIDEO
APPROVED
NOT APPROVED
_________________________
______________________________
Principal
signature
Teacher signature
Return
this form completed and signed to the Principal's Secretary one week before you plan to
show the video. The Principal's
Secretary will have the Principal sign the document.
The form will be returned to you in your mail box.
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