Form Center

2. Name*
3. Email Address
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number
12. Madison Heights Library Card Number*

    Do not use spaces.

16. Type of material*

    1. Book (includes Audiobooks or eBooks)
    2. Magazine or News Source (print or electronic)
    3. Movie, Game, or Audiovisual Materials
    4. Content of Library Program
17. I have read ALL of the following documents:*

    • Madison Heights Public Library Materials Selection Policy
    • Library Bill of Rights
    • Freedom to Read
    • Freedom to View

    1. Yes
    2. No
19. Title*
20. Author or Producer*
22. What brought this title to your attention?*
24. Have you read any reviews about this material? If so, please include the source of the review.*

    Example: “Book about Us” in Publisher’s Weekly, September 27, 2021 Issue or https://www.digitalpw.com/digitalpw/20210927/MobilePagedArticle.action?articleId=1727987 

26. What is your specific objection to the material?*

    Please include specific quotes from the material, including pages numbers for books or how many minutes into the movie a scene occurs, etc.

27. For what age group would you recommend this material? *

    1. Under 5 years old
    2. 5-12 Years
    3. 13-17 Years
    4. 18+ Years
29. Is there anything good about this material? What parts? *
30. What would you like the library to do about this material? *
32. What material do you suggest to provide information on this topic? *

    Please provide specific titles.

33. Would you like to be notified of the library's decision regarding your recommendation?*

    1. Yes
    2. No
Leave This Blank:


34. Submit Submit and Print

* indicates a required field