BELGRADE COMMUNITY LIBRARY

106 N BROADWAY

BELGRADE, MT 59714

406-388-4346

www.belgradelibrary.org

 

Confidential Records Disclosure Request Form

 

Release to Allow Examination of Library Records

 

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 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."

 

PLEASE PRINT

 

My Name

 

_____________________________________________________________________________________


My Library Card Number

 

________________________________________________________________________


Name of the person(s) my library record(s) may be released to:

 

________________________________________________________________________


Signature

 

________________________________________________________________________


Date

 

________________________________________________________________________

 

 

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