H.S. Student Authorization

Student's Name

Student's Address

Student's Signature & Date:

Name of Student's School
High School Instructor
Librarian's Name

High School Instructor/Librarian's Signature & Date:

Parent's Name
Parent's Email Address
Parent's Contact Number

Parent's Signature & Date:

This permit expires at the end of each academic term/semester. Students may borrow up to fie items at a time for a period of 28 days with one renewal.

***************Library Staff Use***************

Patron ID:

Request Received/Entered By:

Date Entered:

Expiration Date: