Permission Slip for Viewing a PG-13/R-rated Movie

Dear Parent/Guardian:

I am planning to show a movie based on as a part of my classes. The movie is rated “R” because there are some scenes of strong, brutal violence and some related nudity. I understand that these particular scenes are inappropriate for your child. For this reason, I will be excluding as many of those scenes as possible without compromising the plot. 

Moreover, I will alert students to any scenes that I cannot exclude. The movie will last for more than two (2) hours and that is why I decided to take four class days to view this film. We will be using a viewing guide which would lead us into a healthy discussion. Students who are not permitted to view the movie will be completing an alternative assignment that I will provide. These students will be spending the four days in the library completing this assignment. This alternative assignment will be directly related to the film as well as its purposes.

Title of the Movie:

Film Showing Date:


Name of the child/student: %child_first_name% %child_last_name%



(Please choose between these options as your response.)


Yes! My child has permission to view the movie.
No! I would prefer my child to complete the alternative assignment.