EMANCIPATED MINOR DECLARATION
(UNDER EIGHTEEN YEARS OF AGE)
Mid-Mississippi Regional Library System
For Staff Use Only:
Emancipation:
Verified
I,____________________________, of __
Not Verified
___________________________________________
(Print Name)
(Print Address)
_________________________________________
(Telephone)
Declare that I am :
•
•
•
FINANCIALLY INDEPENDENT OF PARENTS OR GUARDIANS;
NOT RESIDING WITH PARENTS OR GUARDIANS; AND
RESPONSIBLE FOR MY OWN DEBTS AND OBLIGATIONS.
As an emancipated minor, I authorize the library staff to verify the information below:
Date of Emancipation: ____________
PROOF OF EMANCIPATION:
• COURT EMANCIPATION DECREE (COPY FOR LIBRARY); OR
• CONTACT PARENTS/GUARDIANS TO VERIFY EMANICPATION.
For Staff Use:
(Staff Member)
Verified Emancipation on ___ - ____-____ by ________________________________
spoke with
. Verifying Comment _____________
_____________________________________________________________________
Name of Parents/Guardians________________________________________________
•
Address
____________________________________________________________
________________________________________________________________________
•
Telephone ____________________________________________________________
I certify the above information to be accurate and true.
_______________________________________ ____________ Signature of Minor
Date
Computer/Internet Use and Internet Safety Policies
Mid-Mississippi Regional Library System, Approved: 1-21-10