Sterling Heights Public Library
Library Card Application Form

*Full Name:

*Address:

Apt. #

*City:

*State:

*Zip:

*Gender Male Female

*Telephone Number:

*Birthdate (mm/dd/yyyy):

Driver's License Number (parent’s/guardian’s for children under 18):

*4-digit PIN number for automated renewal service

*E-mail address for automated notification service

I hereby apply for a borrower's card and agree to abide by the rules and regulations of the library, to take care of all materials I borrow, to pay all fines or damages charged to me, and to give prompt notice of a lost card or change of address. Signature ___________________________________________________________________________________ PARENTAL PERMISSION FOR MINOR CHILD (under 18) [Under Section 3 of the Michigan Privacy Act, MLC 397-601 et seq., a library may not release a minor child’s library records unless the parent or legal guardian of the minor child completes and signs this form.] I hereby declare that: (1) I am the mother/father/legal guardian (circle one) of the minor child applying for this library card; and (2) I accept full responsibility for return of library materials checked out by the above-named child, as well as liability for payment for the child’s overdue fines and damaged or lost materials; and I am responsible for any restriction of materials; and (3) I give consent for the release of the child’s library records to: Print responsible person’s names ____________________________________________________________________ Parent’s/Guardian’s Signature _______________________________________________________________________ Parent’s/Guardian’s Birthdate ______/______/______