Program: __________________________________________________________
Program Date: ______________________________________________________
Request Initiated By: _________________________________________________
Address: __________________________________________________________
City: ___________________________________ ZIP Code:_____________________
Phone: ___________________________ Email: _____________________________
This request is made on behalf of: ____ Yourself ____ Organization
Name of Organization: ________________________________________________
Are you currently a resident in the 60466 or 60461 ZIP code? ____________________
What brought this program to your attention? ________________________________
What concerns you about the program? (Please be specific.) _____________________
Have you read the Park Forest Public Library Program Registration Policy? _________
What action are you asking the Park Forest Public Library to consider?_____________
Date: _______________ Signature of Patron: _______________________________
Date: _______________ Received by Staff Member: __________________________