D.H.S.  Media Center Pass      

Date _________________    Teacher’s name ______________________

Name of Student __________________________________ Gr. _______

Purpose of visit (check one)

____ Return/Check out book              ____ Internet Research

____ Book Research                               ____ Other (list below)

          Time:  Left class _______                      Left Media Center _______

                                D.H.S.  Media Center Pass          

Date __________________   Teacher’s name ______________________

Name of Student ___________________________________ Gr. ______

Purpose of visit (check one)

____ Return/Check out book              ____ Internet Research

____ Book Research                         ____ Other (list below)

          Time:  Left class _______                      Left Media Center _______

                                D.H.S.  Media Center Pass                   

Date __________________   Teacher’s name ______________________

Name of Student ___________________________________ Gr. ______

Purpose of visit (check one)

____ Return/Check out book                    ____ Internet Research

____ Book Research                               ____ Other (list below)

            Time:  Left class _______                      Left Media Center _______