Application for Return to the Library form | Pickering Public Library

The personal information on this form is collected under the authority of the Public Libraries Act and the Municipal Freedom of Information and Protection of Privacy Act. This information will only be used for the provision of Library services and programs by the Pickering Public Library. Questions related to the collection of this personal information should be directed by mail: Director, Support Services, Pickering Public Library, One The Esplanade South, Pickering, ON L1V 2R6 or phone: 905-831-6265 ext. 6231.

Return to the Library form

Name

First Last

Birth Date

To be completed if aged 17 years or younger.

Telephone Number

Exclusion Period From (enter start date)

Exclusion Period To (enter end date)

Reason for Exclusion

I understand that when my exclusion period ends, I will need to request reinstatement before returning to the Library. If my reinstatement is approved, I will follow the Welcoming Library Policy by:(Required)

Date

Name of parent or guardian (required)

If you are seventeen (17) years of age or younger, a parent or guardian is required to be part of the reinstatement process.

First Last