Ellensburg Public Library Card Registration Form

First Name *

Middle Name

Last Name *

Permanent Address *

Mailing Address, if different from above

City *

State *

Zip Code *

Phone Number *

Date of Birth (MM/DD/YYYY) *

Email Address *

Are you a student at Central Washington University? *

No, I am not

Yes, I am but only during the academic year

Yes, I am and I live in Ellensburg year round

Upload proof of mailing address (e.g. utility bill) *

Upload proof of identification (e.g. driver's license) *

This application is for someone who is *

17 years of age and younger

18 years of age and older

** ATTENTION PARENT/GUARDIAN IF APPLICANT IS 17 YEARS OLD AND UNDER**

If the applicant is under the age of 17 years old, adult permission must be given. By checking the permission box, you agree to be responsible for all items checked out on the account.

I AGREE I AM RESPONSIBLE FOR THE ITEMS CHECKED OUT ON MY CHILD'S LIBRARY CARD.

I AGREE

MY APPLICATION IS FOR SOMEONE OVER 17 YEARS OF AGE

I GIVE MY CHILD MY PERMISSION TO USE THE COMPUTERS AND INTERNET AT THE LIBRARY.

Yes, I give my permission

No, I DO NOT give my permission

My application is for someone over 17 years of age