Frances L. Simek Memorial Library
Patron Registration Form

To obtain a borrower's card, you will need to print out and complete this form and provide acceptable proof of your name and/or current residence address. PLEASE PRINT

FOR STAFF USE ONLY
Barcode: __2341400_________________________
DOB: __________________________________
Initials: __________________________________

Name_____________________________________________________________________________
(Last, first, middle initial)

Birthday: (month/day/year) _____/_____/_________

Guardian: __________________________________________________________________________
(If under 18, fill in name here and have parent or guardian fill out back)

Telephone#: ___________________________________ Circle one: Home Work Cell

Residence of: _______________________________________________________________________
List name of city, village, township

County: _____________________________

Home Address:______________________________________________________________________
Street address, apartment#, etc.

___________________________________________________________________________
City, State, Zip Code

E-mail Address ___________________________________________________

I apply for the right to use the library. I agree to comply with all the library rules and regulations and give immediate notice of any changes.

Sign your full name ____________________________________________Date __________________

ADULT INTERNET ACCESS CONSENT

Please keep the Internet - Acceptable Use Policy for future reference and return this page of the agreement to Frances L. Simek Memorial Library. This agreement must be signed at Frances L. Simek Memorial Library by the applicant before access to a public Internet workstation will be granted.

I have read the rules concerning Internet access and agree to abide by them. I understand that failure to comply with any of the rules may result in the suspension of termination of Internet access privileges depending on the severity of the offense. Legal action may take place in the case of breach of file security or where action violates local, state, or federal rules, laws, or regulations.

Signature of applicant____________________________________________Date_________________

FOR PATRONS UNDER AGE 18 ONLY - Parent/Guardian needs to complete.

As the parent or legal guardian of this minor, I realize that I am financially responsible for Library materials checked out on this minor's card as well as any fees incurred.

_____________________________________________________________Date_________________
(Parent or Guardian's signature)

PARENT/GUARDIAN
HOME ADDRESS: ________________________________________________________________
(If different from Street address, apartment#, etc.
address on page 1)

________________________________________________________________
City, State, Zip code

Telephone#: ___________________________________ Circle one: Home Work Cell

MINOR INTERNET ACCESS CONSENT

(Note to Librarian: Place note in comment box [pg. 3] on patron's record "Internet OK".)

The parent or guardian of a user under the age of 18 must complete the following:

I have read the rules concerning Internet access. I understand that my child's failure to comply with any of the rules may result in the suspension or termination of Internet access privileges, depending on the severity of the offense. Legal action may take place in the case of breach of file security or where action violates local, state, or federal rules, laws, or regulations.

I hereby grant the Frances L. Simek Memorial Library permission to provide Internet access to my child. I will not hold the Frances L. Simek Memorial Library and the Medford Public Library Board responsible for anything arising from my child's utilization of the Internet at the library.

Signature of parent/guardian_______________________________________________ Date: _____________

CUSTODIAL PARENT/GUARDIAN CERTIFICATION FOR ACCESS TO CHILDREN'S RECORDS

(This section adopted July 12, 2004)

(Note to Librarian: After saving new patron info, go to Blocks, Add Note, Comment and input "C/P and parent's name".)

I hereby certify that I am the custodial parent or guardian for _____________________________________ and pursuant to 43.30 Wisconsin Statutes, hereby request to review the following Library records pertaining to this child's use of the Library's documents or other materials, resources, or services.

Requested records:
          __________Current items checked out
          __________Current overdue materials
          __________Outstanding fines and fees
          __________Current holds

Signature of parent/guardian_______________________________________________ Date: _____________

The Library will not release personal information about this child. The Library maintains only current records on customer use of the Library. The Library does not maintain records other than those listed above. In signing this document, I certify that the child whose records I am requesting is 16 years old or less.

INTERNET - ACCEPTABLE USE POLICY

Use of the Internet is a privilege, not a right; inappropriate use will result in a cancellation of this privilege. When using a public Internet workstation at the Frances L. Simek Memorial Library, you agree to the following policy:

Ethical Use

Responsible and ethical use of the Internet resources include the following:

Using the electronic information resources at the Frances L. Simek Memorial Library in a responsible manner, consistent with the educational and informational purposes for which they are provided.
Not using the Internet for any unauthorized, unethical, or illegal purpose.
Respecting the privacy of others by not misrepresenting oneself as another user.
Not attempting to modify or gain access to files, passwords, or data belonging to others.
Not seeking unauthorized access to any computer system or damaging or altering software components of any network or database.
Not sending, receiving or displaying text or graphics which may reasonably be construed as obscene.
Not making any changes to the setup or configuration of the software or hardware.

Internet User Agreement

Frances L. Simek Memorial Library's Internet access does not include chat groups.

Library staff will assist patrons with Internet use as time permits, but may not be familiar with every application that a person might wish to use and, therefore, cannot be expected to provide complete technical support.

A per page printing charge will be assessed. Payment is made at the Circulation Desk.

Computer reservations and use may be limited to 2 hours per week per person. To support access for all users, the library has the right to enforce posted time limits. If no one is waiting, the user may continue Internet use.

Any person found to be disclosing, disseminating, or using personal identification information of a minor in an unauthorized manner will be reported to the appropriate law enforcement agencies. This person will also be prohibited from further use of computers while in the library.

Misuse or abuse of the computer or the Internet access will result in the suspension of the computer privilege.

Children Under the Age of 18

Children under the age of 18 must have a parent or guardian complete an INTERNET ACCESS CONSENT FORM to be kept on file at the library. Children under the age of 18 will be limited to designated filtered machines.

Frances L. Simek Memorial Library assumes no responsibility for the use of the Internet. It is the responsibility of the caregiver, guardian or parent to determine what is appropriate. Library staff is not responsible for monitoring access to the Internet.

If unacceptable use occurs after fair warning by the library staff, a child's Internet privileges will be takes away. The following minimum guidelines will be used:

First offence - 2 week wait
Second offense - 4 week wait; parent/guardian notified
Third offense - Loss of privilege for a period of time determined by the library director; parent/guardian notified

Library's Rights Reserved

The Frances L. Simek Memorial Library reserves the right:

to terminate the user's session, without notice.
to limit the amount of computer time at any one sitting.
to immediately suspend persons from computer use for violating these rules and regulations.
to limit the software available to users to library owned resources and to deny the loading of user provided software.

Disclaimer

Just like with other resources of information, the library is not responsible for the validity or reliability of the information found on the Internet. users are cautioned that the accuracy, completeness, and currency of information found on the Internet varies widely.