Home delivery application

Home delivery application
Our Home Delivery service offers delivery and pick-up of materials throughout Lucas County to people who are physically unable to visit a library due to a medical reason. We’ll select materials based upon your general interests or requests and bring them to your door every four weeks.
Completed
I am eligible for Home Delivery as I am unable to use or travel to a Library location due to a medical reason.*

Yes
Are you unable to use or travel to a Library location due to a medical reason?

YesNo
Name*

First nameLast name
Address

Street address

Street address line 2

CityState / province

Postal / ZIP code
Phone Number*
Format: (000) 000-0000.
Phone number*
Email
Date of birth:*
Contact name & phone number (if different than patron)
Alternate contact name

First nameLast name
Alternate phone number
Format: (000) 000-0000.
Alternate phone number
Alternate email
Do you have a Library card?

YesNo
Are you unable to use or travel to a Library location due to a medical reason?

YesNo
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 booksLarge print booksMoviesAudio booksMusic
Any special instructions or comments:
After submitting this form, a librarian will contact you to discuss further details about Home Delivery service.

Call us at 419.214.4663 for help.
Should be Empty: