Chemung County Library District

Parental Consent Form

To parents and guardians of library users: As you will read from the library's Internet Policy, Internet access is provided to individuals under the age of 16 only after a parent or guardian grants written permission.  If you wish to grant your child these privileges, please print and sign the form below and return it to the library.

I, __________________________________________________________, certify that I am the parent or legal guardian of:

____________________________________________________________ . I hereby grant permission for my child to use the electronic resources of the Internet.

Birthdate: ______________________________________________________

Child's Library Card Number: ____________________________________

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