First Name: (required)

Last Name: (required)

E-Mail Address: (required)

Name of Program:

Home Address: (required)

City: (required)

State:     ZIP: (required)

Home Phone Number:

Work Phone Number:

Driver's License Number ot State ID: (required)

Client Type: Other CRS Staff SNU Respite Provider Parent Parent Educator Student Family Child Care Provider Center Based Staff College Instructor Trainer/Consultant

If other please explain:

Secondary contact in case we cannot reach you regarding library materials (REQUIRED):

Name: (required)

Relationship to Applicant: (required)

Home Phone: (required)

Work Phone:

Please read carefully:
Your Library Card must be presented each time any library materials are borrowed. You are responsible for any and all library materials (including toys, videos, books, cassettes, computer disks, or modules) borrowed on this card, with or without your consent. Return library materials on time and in good condition to a representative of the library at any branch. REPORT LOSS OF CARD OR CHANGE OF NAME OR ADDRESS IMMEDIATELY. The card may be revoked by CRS Library Staff at any time.

I have read and understood the preceding agreement