Parental Notice of Intended Movie Performance

(Rating Issue Involved)


It is my intent to use a movie created primarily for entertainment purposes as part of the instruction in your child's classroom.  This is done because the subject of the movie, and treatment of the subject, are very closely related to the curriculum of the Rochester School Department and instructional objectives in the course that I teach and will, in my opinion, provide a better understanding of the topic than other available materials.


Please note that the rating of this movie may warrant your special attention.


Please review the following information, sign and return this form to indicate whether you do or do not  wish to permit your son/daughter to view the movie selection.  Please note: If this form is not returned, your son/daughter will not be permitted to view the movie selection:


Name of Movie:                                                                                                                                  

MPAA Rating:                          Proposed Date:                                 Selection Length:                        

Portions of this movie selected for showing in my class   r do     r do not   include material that may have led to the rating assigned to the movie.

How this selection is related to the district's curriculum and instruction:                                                  




If you do not wish to have your son/daughter view the movie selection, another activity will be provided that is related to the same topic so that no instructional time will be lost.


Thank you,

Teacher Signature




Please complete, sign, detach and return this section:


I hereby   r do     r do not    grant permission for my son/daughter, ____________________________, to view selections from the movie, [Movie Title], at school on [Date].



                                                                                    Parent Signature