DELAWARE Registration Form



Library 

CARD 

Modified: 7/30/2008 

Basic Info 
LAST NAME, FIRST: 
Gender: 
Smith Jr., Robert 
Barcode: 
Profile: ADULT JUVENILE, internet access FULL, T1, T2, NO 
Net Only 
Date of Birth: 
Addresses 
Street: 
P.O. Box: 
Primary Address 
Apt #: 
City/State: Zip: 
Secondary Address 
Male Female 
County: 
Street: 
P.O. Box: 
Apt #: 
Phone: 
City/State: Zip: County: 
Driver’s License: State: 
Date: 
NRPONONRES Temp 
Optional if over 
18yrs of age 
Contact Me By 
Phone: 
Secondary 
Phone: 
Mail: 
Email: 
(see above) 
Please check one: 
Other: 

Signature 
I agree to report a lost card or change of address. I agree to pay all charges on my account and 
observe all library policies and use standards. 
Guardian Info 
Please Print Parent or Guardian Name: 
Signature: 
Required for children 17 and under 
Street: 
P.O. Box: 
Apt #: 
Home Phone: 
City/State: Zip: County: 
Address if different from juvenile 
“I understand that the Library does not accept responsibility for my child’s choice of library 
materials and that I am responsible for fines and fees of materials checked out by my child.” 
“I have read the Library’s Internet Policy and wish to give my child the following access to Internet 
or other online services.” 
Tier 2 Access 
For Grades K-12 
PC use only/No Internet AccessFull Internet Access 
To be completed in the library by parent or guardian 
Demographics 
Full 
Tier 2 Grade 6-12 
None PC Use Only 
No Internet 
Access 
Education Level: 
Preschool 
Elementary Grades 1-5 
Middle Grades 6-8 
High School Grades 9-12 
College No Degree 
2 yr 
MA PhD 
4 yr 
Full Internet 
Access 
Trade School 
Ethnicity: 
Asian 
African Amer. 
Hispanic 
Native Amer. 
White 
Residency: 
City of Dover 
City of Harrington 
City of Smyrna 
Milford Schl. Dist. 
Kent Co. 
New Castle Co. 
Sussex Co. Other 
Optional 
Optional 
Inter-
net 
Internet ac-
cess (public 
library only) 
Tier 1 Grade K-5 
Modified: 7/1/2008