Belgrade Community Library

Empowering a community of lifelong learners

 

106 N BROADWAY

BELGRADE, MT 59714

(406)388-4346

www.belgradelibrary.org

 

ASSUMPTION OF FINANCIAL RESPONSIBILITY BY A MINOR

 

 

I agree to assume responsibility for all materials checked out on my account including any fines, fees, or other charges that are accrued through use of this account.

 

By assuming this responsibility, any guardian or other financially responsible individual previously listed on my account will be removed from the account and no longer have any financial responsibility for fines, fees, or other charges associated with this account.

 

No individual beside the card holder will be provided access to account information or use of this account unless granted written permission by the cardholder using the Confidential Records Disclosure form.

 

 

PLEASE PRINT


Patron Name                                                                                     Patron Library Card Number

 

__________________________________________                __________________________________





Patron Signature

 

________________________________________________________________________                                               

 

Date

 

________________________________________________________________________                                               

 

Staff Initials for Confirmation _____________________________

 

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