Parental Consent Form

By signing below, I assume responsibility for my child's actions and acknowledge that restriction of my child's access to the Internet is solely my responsibility as his/her parent/guardian.

I have read the Rules for the Use of Public Computers and have instructed my child in the rules governing the Library’s Internet access. I realize that not every site on the Internet may be desirable for underage individuals. I understand these rules and the Library’s position and agree to abide by the guidelines and policies.



I give my permission for my child to use the Internet station unattended. YES ______

Parent or Guardian’s Signature

__________________________________________________

Please print name of parent below and name of child covered in this consent form (Please use a separate form for each child using the Internet.):

Parent:__________________________________________________________________

Child's Name: _______________________________________

School Grade: _______________________________________

Date: ________________

Child's Library Bar Code Number (if available)

_________________________________________________

Address__________________________________________

Phone______________________



Approved by the Roxana Public Library District Board of Trustees; revised November, 1999; February , 2006.