Application
for Library Card - Youth
A
library card confers privileges and carries responsibilities. Your application
shows that you want the privileges and accept the responsibilities. Responsibility for any supervision of your
reading and your use of all the Library's resources in any format, including
Internet access, belongs to your parent(s) or legal guardian(s). The card
is your identification and is not transferable. Library records which contain
names or other details about library users are confidential under NYS law.
PLEASE
PRINT
NAME
Last
name: ___________________________________________ First
name: _____________________________MI: ____________
(full
middle name, if used)
Title:
_______________________ Suffix:
________________ Preferred
name: _____________________________
(optional: Mr, Mrs, Miss, Ms or other honorific) (Jr, Sr)
(optional:
AKA, nickname, or other name)
MAILING
ADDRESS (1)
Care
of (the adult you live with): _________________________________________________________________________________
street:
_____________________________________________________________________________________________________
city/state:
___________________________________________________________________ zip code:
________________________
home phone:
______________________________ other phone (cell, second home phone):
_________________________________
e-mail (optional):
_____________________________________________________________________________________________
school: :
________________________________________________ Birth date: __________ / __________ /
__________
(month) (day) (year)
work phone of parent/guardian:
____________________________________
PARENT/GUARDIAN
NAME AND/OR ADDRESS (3) (If
different than the above care of and address):
last name:
_________________________________________ ,
first name: ________________________________MI: ____________
(include
jr or sr, if used)
(full middle name,
if used)
street:
_____________________________________________________________________________________________________
city/state:
___________________________________________________________________ zip code:
________________________
home phone:
______________________________ other phone (cell, second home phone):
_________________________________
use for (specify season, months or
other time period):
________________________________________________________________
PLEASE
READ CAREFULLY AND SIGN (Parent/Legal
Guardian please read both paragraphs)
I agree to observe all rules established by the
library, including, but not limited to, its Rules of
Conduct and Internet Access Policy. I will be responsible for all materials
borrowed on my card. I agree to pay fines or other charges imposed for late
return, loss or mutilation of library materials. I will notify the library if
my card is lost, or if I change my name or address.
Youth
Applicant's
Signature___________________________________________________________________________________
As parent or legal guardian, I understand that
responsibility for supervision of my child’s selection of materials and use of
all the library's resources in any format, including the Internet, belongs to
me, not to the library staff.
Parent's
or Legal Guardian's
Signature___________________________________________________________________________
TO
BE COMPLETED BY STAFF: CARD
NUMBER:
|
Basic library:____________________ profile
name: ______________ |
Privilege PIN:
_____________________ change to the
last 4 digits of primary mailing address home phone; inform customer. |
Demographic Tax
Code: _________________ County:
____________________ Qualifier:
___________________ |
Type of
registration: ____
new ____
re-registration ____
change name/address ____
worn, lost, stolen card ____
other: ____________ |
Library:
__________________________________ Staff: ___________________________________ Date:
_____________________
app-youth form rev 12/14/2009