Confidential Records Disclosure Request Form

2. By my signature below I give written consent for Belgrade Community Library to disclose my library records and grant use of my library account to the person(s) listed.

   I understand that I must give written permission to release my library records.

   I understand that Article II Part II Section 15 of the Montana Constitution states: "Rights of persons not adults. The rights of persons under 18 years of age shall include, but not be limited to, all the fundamental rights of this Article unless specifically precluded by laws which enhance the protection of such persons."

4. Name
6. Library Card Number
8. Name of the person(s) my library record(s) may be released to:
10. eSignature
11. Date
    Date

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

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

    This field is not part of the form submission.

17. Submit

* indicates a required field