Question Form - Westchester Connections

Registering Agency Contact

Use this section if you are registering a Welcome Back card for your client.

Agency name *

Full name of person registering the card on a client's behalf *

Email of person registering the card on a client's behalf *

Phone number of person registering the card on a client's behalf *

Patron Information

Registering agencies can complete this section on a client's behalf.

Full name *

Preferred gender *

Female

Male

Other

Prefer not to say

Date of birth (use format mm/dd/yyyy) *

Street address *

Building/apartment/room number

City, State, and Zipcode *

Patron Email *

Patron phone number *

If your client ever had a library card from any Westchester library, please provide a prior address

WLS card number (as printed below the barcode on the Welcome Back card) *

Re-enter WLS card number *

More Detail/Explanation *

Fields marked with * are required.