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2. First Name*
3. Middle Name*
4. Last Name*
6. School*
7. Grade*
   -- Select One --KindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelfth
9. School-Issued Student Identification Number*
   LEAP Pass number will be "30" + Student ID number. If Student ID is less than 10 digits, please add zeros at the end.
10. Birthdate*
    Birthdate
    Password/PIN for LEAP Pass will be Birth Month and Birth Day (MM/DD).
11. Gender*
    -- Select One --MaleFemale
13. Address*
15. City*
16. State*
17. Zip Code*
19. Parent/Legal Guardian First Name*
20. Parent/Legal Guardian Last Name*
22. Parent/Legal Guardian Phone Number*
23. Parent/Legal Guardian Email Address*
25. Please allow 2-3 business days for the LEAP Pass to be activated in our system.
27. Electronic Signature Agreement*

    By completing and submitting the online LEAP Pass Registration Form, the responsible adult acknowledges that Onslow County Public Library does not filter its digital media collections or online resources, and is not responsible for electronic resource content accessed by the student.

    1. I agree.
29. Electronic Signature*
30. Date*
    Date
Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field