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:

I request the filtering adjustment for the following time period:

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 authorites. I hereby release the district and its Board members, employees and agents from any claims an damages arising form my use of, or inability to use, the district's Internet, computers and network resources.

**For students only, parent/guardian permission is requried 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.

**Submit this form to the building principal. Decisions to deny access may be appealed to the Superintendent or designee for expedited review.

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For District Use Only