Instructions: Complete both parts of this application. A parent or legal guardian is responsible for materials checked out on his or her child’s card and must sign this application. Part 1 (To be completed by child or parent/guardian.) Please Print. Enter only one letter or number in each box. Child’s Name and Mailing Address Home Address (if different from above) Child Library Card Application (Ages 12 & under) Date:__________________________ Last Name First Name Street Address Street Address Apt. # Apt. # Borough or City City State State Zip Code Zip Code Email Address Area Code Telephone Number Male Female Mi ddl e I nitial Dat e of Birth (Month/Da y/ Y ear) This section for staff use only NEW: LOST/REPL.: TRANSFER: PTYPE: EXP . DATE: Complete: Staff Initials Parent/Guardian Signature 5 7 8 2 . F M A. My chil d may borrow ad ult as well as children’ s materials. B. My child may borrow children’s materials only. Parent/Gu ardian is responsible for materials checked out on child’s card. Part 2 (To be completed by parent/guardian.) Parent/Guardian: Please print your name, check box A or B and then sign your name. Last Name First Name Middle Name or Initial (Optional) (Optional)
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Transcript
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Instructions: Complete both parts of this application. A parent or legal guardian is responsible for materials checked out on his or her childs card and must sign this application.
Part 1 (To be completed by child or parent/guardian.) Please Print. Enter only one letter or number in each box.
Childs Name and Mailing Address
Home Address (if different from above)
ChildLibrary Card Application (Ages 12 & under)
Date:__________________________
Last Name
First Name
Street Address
Street Address
Apt. #
Apt. #
Borough or City
City
State
State
Zip Code
Zip Code
Email Address
Area Code Telephone Number Male Female
Middle Initial Date of Birth (Month/Day/Year)
This section for staff use only
NEW: LOST/REPL.: TRANSFER: PTYPE: EXP. DATE: Complete:
Staff Initials
Parent/Guardian Signature
5782.FM
A. My child may borrow adult as well as childrens materials.
B. My child may borrow childrens materials only.
Parent/Guardian is responsible for materials checked out on childs card.
Part 2 (To be completed by parent/guardian.)
Parent/Guardian: Please print your name, check box A or B and then sign your name.
Last Name
First Name Middle Name or Initial
(Optional)(Optional)
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