The Agnes Robinson Waterloo Public Library

23704 Cedar Drive

Waterloo, NE 68069

Phone: 402-779-4171

Fax: 402-779-4369

Registration Form

Child's Name _________________________________ DOB ______________________

Parent/Guardian _____________________________________________________________

Address ______________________________________________________________________

Email _________________________________________________________________________

Phone Number ______________________________ Date Enrolled ______________

I understand that in submitting this form I am giving permission for me (and my child) to participate in the 1000 Books Before Kindergarten Event at Agnes Robinson Waterloo Public Library. I agree to monitor using the logs provided by the Library.

Permission to Videotape and/or Photograph

I __________________________ am 18 years old or older. I _______________________ am the

(Name, please print) (Name, please print)

parent or guardian of _________________________. I understand that Agnes Robinson

(Name and age)

Waterloo Public Library may photograph or videotape the events or activities in which I (or my child is) participating. I give my permission for the City to use photographs or videotape of me (or my child) for the purpose of promoting the Agnes Robinson Waterloo Public Library and its services/programs. I give permission with the following understanding. No compensation of any kind will be paid to me (or my child) at this time or in the future for the use of my (or my child's) likeness. Permission is not required to take part in library events.

Signature: _________________________________________Date: ________________________

Address:__________________________________________City, Zip: _____________

Phone: __________________________________________________________