MONTGOMERY CITY PUBLIC LIBRARY

INFORMED CONSENT FOR LIBRARY USE BY MINOR

 I (Printed Name) _________________________________________ am the PARENT or LEGAL GUARDIAN of the minor (ages 17 or younger) whose name is ________________________________________.  I am aware that such Child has a library card granting access to the content at the Montgomery City Public Library, which may include print or electronic materials of books, periodicals, trade information, websites, DVDs, or the like, and that such information may include both fiction and nonfiction written information and that some electronic sources may include video or other interactive portions of content.

MCPL checkout systems do not recognize the recommended age group or movie ratings of materials.  Therefore, parents and guardians are responsible for the materials viewed, browsed, accessed, checked out, lost, or damaged by their children.

I understand that the Montgomery City Public Library staff, director, or other official persons affiliated with the Library do not have supervisory duty over my Child and that it is my responsibility to monitor the Child’s behavior and consumption of content, in any and all forms. 

_____ I provide consent for my Child to check out content and utilize MCPL resources.

_____ I do not provide consent for my Child to check out content and utilize MCPL resources without my approval for each and every such instance and item.  Therefore, a parent or legal guardian will be present with my Child at checkout.           

MINOR’S BIRTHDATE: __________________________

MINOR’S MCPL CARD NUMBER:_______________________________________________

DATE COMPLETED: __________________________

SIGNATURE OF PARENT/GUARDIAN: __________________________________________

ADDRESS OF PARENT/GUARDIAN:____________________________________________

__________________________________________________________________________

EMAIL OF PARENT/GUARDIAN:________________________________________________

PHONE OF PARENT/GUARDIAN:______________________________________________