Common use of Check one box Clause in Contracts

Check one box. □ 1 person □ 6 persons □ 2 persons □ 7 persons □ 3 persons □ 8 persons □ 4 persons □ Over 9 persons □ 5 persons Household/Family Income Summary Check one box □ $42,850 or below family income □ $71,400 or below family income □ $106,000 or below family income □ $139,950 or above family income □ Other: Hispanic: Yes / No □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Pacific Islander Ethnicity Check one box □ American Indian/White □ Asian/White □ Black/White □ American Indian/Black □ Other/Multi-Racial I acknowledge that the Tech Lending Library Services are intended for library patrons who do not otherwise haveaccess to the equipment or services sufficient to meet the patron’s educational needs. To the best of my knowledge, the information above is correct and I fully understand that the information provided will be shared with the Library Services special grant reporting purposes, where names and identifiable information will be removed. Signature: Date: Email Address: Library card # Demographic Information (REQUIRED): Cell/Home #: Gender: Male/Female [ ] Chromebook Serial Number Issued: [ ] Mi-Fi (up to 1 device) Serial Number Issued: [ ] Samsung Tablet Serial Number Issued: Yellow Green Orange Device Check-Out Date: Device Return Date: • Hayward Public Library’s technology equipment may be checked-out by Hayward residents whom otherwise do not have access to broadband internet or a computing device, who are 18 years and older, and complete this Borrowing Policy & Agreement Form. • A valid Hayward Public Library card number is required. • A borrower must read, understand, and sign this agreement before any technology equipment is checked- out. • The loan period for technology equipment check-out is 12 weeks. After the last day of the loan period, any late or unreturned devices will be disabled and rendered useless after the 2 day grace period. • All equipment and peripherals (boxes, power brick, etc.) must be returned on or before the due date and time indicated.

Check one box. □ 1 person □ 6 persons □ 2 persons □ 7 persons □ 3 persons □ 8 persons □ 4 persons □ Over 9 persons □ 5 persons Household/Family Income Summary Check one box □ $42,850 39,150 or below family income □ $71,400 65,250 or below family income □ $106,000 104,400 or below family income □ $139,950 137,850 or above family income □ Other: Hispanic: Yes / No □ White □ Black/African American □ Asian □ American Indian/Alaskan Native □ Native Hawaiian/Pacific Islander Ethnicity Check one box □ American Indian/White □ Asian/White □ Black/White □ American Indian/Black □ Other/Multi-Racial I acknowledge that the Tech Lending Library Services are intended for library patrons who do not otherwise haveaccess to the equipment or services sufficient to meet the patron’s educational needs. To the best of my knowledge, the information above is correct and I fully understand that the information provided will be shared with the Library Services special grant reporting purposes, where names and identifiable information will be removed. Signature: Date: Email Address: Library card # Demographic Information (REQUIRED): Cell/Home #: Gender: Male/Female [ ] Chromebook Serial Number Issued: [ ] Mi-Fi (up to 1 device) Serial Number Issued: [ ] Samsung Tablet Serial Number Issued: Yellow Green Orange Device Check-Out Date: Device Return Date: • Hayward Public Library’s technology equipment may be checked-out by Hayward residents whom otherwise do not have access to broadband internet or a computing device, who are 18 years and older, and complete this Borrowing Policy & Agreement Form. • A valid Hayward Public Library card number is required. • A borrower must read, understand, and sign this agreement before any technology equipment is checked- out. • The loan period for technology equipment check-out is 12 weeks. After the last day of the loan period, any late or unreturned devices will be disabled and rendered useless after the 2 day grace period. • All equipment and peripherals (boxes, power brick, etc.) must be returned on or before the due date and time indicated.