Summer Reading Program

Child's Full Name

Age and Birthdate

Grade in Fall 2025

School Name in Fall 2025

Parent/Guardian Full Name

Parent/Guardian Email

Parent/Guardian Phone

Parent/Guardian Address

Other Emergency Contact/Phone

Allergies or any other info we should know

By checking this box, I understand the Heritage Public Library may photograph or videotape the events or activities in which I am (or my child is) participating. I give my permission for the Heritage Public Library to use photographs or videotape of me (or my child) for the purpose of promoting the Heritage Public Library and its services/programs. I give my 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 this program.

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