Applicant First Name:

Applicant Last Name:

Parent (s) /Legal Guardian(s) if applicants 12 & under:

Address

Apt/Unit#:

Street Address:

City:

Postal Code:

Email:

Pronouns (Select All That Apply):
He/HimShe/HerThey/Them

Applicant Birth Date:

Receive Library Notices (Select All That Apply):
By EmailBy PhoneBy Text

Blackstone Foundation Library Program that you are involved in:
Seeds Of WisdomDo The KnowledgeVolunteerBook clubN/A

Any questions or comments (optional)

By signing below I agree to:
1. To be responsible for the library card and all materials borrowed under my name.
2. I confirm that the information I have provided is accurate and up to date, and will report any changes.
3. I understand that misuse of this card may result in the suspension of borrowing privileges.
4. To report changes in my registration information (legal name, address, contact information).
5. One item may be borrowed out from the library at a time by library members.
6. Lending period will be 14 days for ebooks and audiobooks. Default lending period is 7 days.
7. I agree to comply with the terms and conditions of the Privacy Policy

I hereby grant permission for Blackstone Foundation Library to collect data for the purposes of statistics and
reporting.

The applicant, or parent/legal guardian if the applicant is 12 & under, agrees to be responsible for all materials borrowed and to abide by the rules and regulations of Blackstone Foundation Library. The information on this form
is collected in accordance with the Freedom of Information and Protection of Privacy Act.

Signature of the applicant or parent/ guardian, if applicant is 12 & under: