First name

Last name

Birthday

Month

Day

Year

Gender

Address

Phone Number

I understand that borrowing items from the library is a privilege.
I promise to take care of the materials that I borrow and I will return them on time.
I will pay for any material that is lost or damaged while it is checked out to me.
I understand that I will not be able to check out additional materials while I have overdue or lost materials on my account.
I agree to follow the policy, procedures and rules of the library.

Patron Signature (must be signed in person at the WCPL):

Signature field is empty.

Emergency Contact (Name, Relationship, Phone Number):

Staff Use Only

Date

Month

Day

Year

Staff Name:

Membership Type:

Library Card Number:

Expiration Date

Month

Day

Year

Driver's License/ID Number:

PLAC Number (if applicable):

Adult Services Manager Initials:

Information + Inspiration for a Brighter Wabash