I give my child , ___________________________
permission to be at the Gallatin Co. Library on (date)_____________________________, from 5:00 P.M. to 10:00 P.M. I understand that the library will not be held responsible for any injury that may occur during this time. I will be picking my child up unless other arrangements have been made with the Library staff.


Parent's name

_________________________________________



Child's age

_________________________________________


Address

_________________________________________

__________________________________

Phone

_________________________________________

Names of others who may pick up my child

_____________________________________


List any allergies or medications my child may need during this time:


________________________________________________

________________________________________________

________________________________________________


My Teen has my permission to use My Space on the Internet (Check One) __________Yes __________No

NOTE: THIS FORM MUST BE AT THE LIBRARY WHEN THE TEEN INITIALLY ARRIVES FOR TEEN NIGHT. ALL TEENS MUST BE CHECKED-IN NOT LATER THAN 5:30 P.M. WE CANNOT ACCEPT TELEPHONE REGISTRATION.