Add New Junior Member (To be completed by Parent or Guardian for any member under 16 years) Member# 1000000782, Card Number* PARENT OR GUARDIAN No Title Miss Mrs Ms Mr Dr Sir Title Given Names* Surname* Library No. L - Levin F - Foxton S - Shannon H - Horowhenua K - Kapiti O - Out of District X - Temporary Visitor Z - Interloan Libraries V - Villlage Postal Address* Town* Area Street Address if different Town NAMES OF ALL CHILDREN NEEDING CARDS F M* Given Names* Surname* School Date of Birth (dd/mm/yy)* F M* Given Names* Surname* School Date of Birth (dd/mm/yy)* F M* Given Names* Surname* School Date of Birth (dd/mm/yy)* European/Pakeha Maori Asian Pacific Island Other - please specify--> Child Ethnicity Ethnicity Notes Membership Category* MEMBER CONTACT DETAILS Phone (Home) Phone (day) Fax Email ALTERNATE CONTACT DETAILS Relative Friend Neighbour Name* Phone Relationship* Notes LIBRARY USE Notes
(To be completed by Parent or Guardian for any member under 16 years)