Request for Copyright Exceptions Form page 1

e request permission to post the following Region 4 resources within our learning management system (LMS) for the
202-202 school year.

1. We certify that we have a purchased copy for each teacher for whose instructional use these activities will be
posted. 2. We have listed below the exact title of each Region 4 resource and pages for which we make this request. 3. We understand that permission will be considered for all resources with the exception of Reading by Design.

We certify that this request is solely for the 202-202 school year. We agree to remove access to these resources at
the close of the 202-202 school year. We understand that this approval process is complete once Region 4 has
returned a signed copy to us.

Printed Name of Requestor

Printed Name of Region 4 Approver

Title

Organization

Department

Digital Signature

Request for Copyright Exceptions Form Page 1 (1 of 3)

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