Assumption of Financial Responsibility by a Minor Form

2. I agree to assume responsibility for all materials checked out on my account including any fines, fees, or other charges that are accrued through use of this account.

   By assuming this responsibility, any guardian or other financially responsible individual previously listed on my account will be removed from the account and no longer have any financial responsibility for fines, fees, or other charges associated with this account.

   No individual beside the card holder will be provided access to account information or use of this account unless granted written permission by the cardholder using the Confidential Records Disclosure form.

4. Patron Name
6. Patron Library Card Number
8. Electronic Signature Agreement

   By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

   1. I agree.
10. Electronic Signature
11. Date
    Date

14. This form and subsequent releases will be kept on file until otherwise requested by the patron.

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16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field