Rated R/TV-MA DVD Loan Form (for children under the age of 17)


Your child is requesting to borrow a DVD(s) that is Rated R (restricted to 17+)/TV-MA (mature audience only).  The Annie Porter Ainsworth Memorial Library requires parent/guardian permission to have a child check the DVD(s) out.  When this form is submitted, a corresponding note will be placed on your child’s library account.  Library staff will then permit your child to borrow any DVD.  

By completing this form, I understand that I am allowing my child (under the age of 17) to borrow any DVD, regardless of rating, from the Annie Porter Ainsworth Memorial Library.        

Child’s Full Name ____________________

Parent’s/Guardian’s Name (please print) ___________________________________

Parent’s/Guardian’s Signature ____________________________________

Parent’s/Guardian’s Phone Number ____________________________________

Approved 8/15/17