JTL Summer Reading Program 2019
Please list first and last name. (Ex: Hermione Granger)
Please select your current age from the drop-down menu.
School I attend:
Please select which school/program you currently attend. (Ex: Hogwarts)
Browns River Middle School
Jericho Elementary School
Mount Mansfield Union High School
Mansfield Cooperative School
Poker Hill School
Saxon Hill Co-Op
Smilie Memorial School
Underhill Central School
Please select your current grade level. (Example: Prefect)
Phone number where you can be reached:
Email address where you can be reached:
Do you (or a family member) have a library card?
Yes, of course!
Not yet--but I'm interested in getting one!
I'm not sure.
I hereby grant and authorize to take photographs as detailed below:
I hereby grant and authorize the Jericho Town Library the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languages, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of Jericho Town Library and will not be returned. I hereby hold Jericho Town Library harmless, and release from all liability, petitions, and causes of action which I, my heirs, representative, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.
Yes, I agree. Take as many photos as you'd like!
You're amazing! If you signed up online, don't forget to stop by JTL to pick up your reading log & SRP goodie bag!
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This form was created inside of Jericho Town Library.