Library Card Application for Minors [2022]

Application for Minors

Do you live in the Chelsea Library District? (required) ::

Under Section 3 of the Michigan Library Privacy Act (MLC 397.601), a library may not release information on a minor's child's library record unless the parent or legal guardian of the minor completes and signs the following:

Parent/Guardian Name (required) ::

Full Legal Name of Minor Child (required) ::

Date of Birth (required) ::

I hereby declare that:

I am (required) ::

I accept full responsibility for the return of all library materials checked out by the minor, as well as liability for payment of their fines, damages and lost materials. (required) ::

I give consent for the release of the minor's library records to myself and/or (name required) ::

Relationship to Minor::

My 16-17 year old minor can renew their card using their current Michigan drivers license. I will be responsible for renewing younger minor's cards (required) ::

If renewing, what is your current card number ::

Are you renewing an existing Library Card? (required) ::

Please provide a VALID Email Address (required) ::

Would you like to get our Weekly eNews letter via eMail (required) ::

Preferred Name (required) ::

Address1: Number, Street, Apt# [If Any] (required) ::
Address2: (If needed) ::
City (required) ::
Zip Code (required) ::
Township (required) ::

Minor Phone ::

Parent Driver License Number (required) ::

Minor Driver License Number (optional) ::

Parent Phone (required) ::

Would you like to receive our eNewsLetter (required) ::

Would you like to receive TEXT Messages (required) ::

If YES, who is your mobile service provider? ::

As the parent/legal guardian of the above minor child, I have read and understand the library's rules on internet and library card use. I understand that noncompliance by myself or my child will result in revocation of privileges. I will promptly report loss/theft of this card to library staff.

I have read and understand that filtering technology is used as a tool only and that no method of filtering is guaranteed. I hold the library harmless for any information that my minor child may seek or find on the internet. This application is the property of Chelsea District Library.

I certify that the information on this form is correct. I accept responsibility for the materials borrowed on the library card issued from this application. Responsibility for the choice of materials borrowed rests with the person who filled out this application and not with the Chelsea District Library or its staff. (required) ::

Parent Driver License Only: FRONT (required)

Parent Driver License Only: BACK (required)