HOMEBOUND SERVICES APPLICATION

HOMEBOUND SERVICES APPLICATION
Our Homebound Service offers delivery and pick-up of materials throughout Lucas County to people who are physically unable to visit a library. We’ll select materials based upon your general interests or requests and bring them to your door every four weeks.
Completed
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email
example@example.com
Date of Birth: *

Month Day Year
Contact Name & Phone Number: (If different than patron)
Alternate Contact Name

First Name Last Name
Alternate Phone Number

Area Code Phone Number
Alternate Email
example@example.com
Do you have a library card?

Yes No
I am eligible for this service because I am: (Please check all that apply)

unable to use a library facility. unable to travel to a library.
Please explain:
Would you like the material in the following format(s)? (Please check all that apply.)

Standard Print Books Large Print Books Movies Audio Books Music
Any special instructions or comments:
After submitting this form, a librarian will contact you to discuss further details about Homebound Service.
Should be Empty: