Books on Wheels Registration

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This form is for qualifying and enrolling in Cottage Grove Public Library's homebound services.

Qualification for Homebound Delivery through Cottage Grove Public Library *

I live within Cottage Grove city limits

I live outside of city limits

Other:

At least one of these must apply: *

Short-term disability

Long-term disability

Illness which confines individual to their home

75 years or older

Required

Name *

Street Address *

City, State, Zip Code *

Home Phone *

Choose the best days and times to call you

Monday

Tuesday

Wednesday

Thursday

Friday

Morning [9am-12pm]

Afternoon [1pm-5pm]

Do you reside in a residential care facility or an apartment complex?

Yes

Clear selection

If "yes", facility name

Name of person helping fill out this form

Should library staff contact the person helping to fill out this form about applicant's reading preferences?

Yes

Clear selection

If "yes", phone number

By selecting this checkbox I understand and agree to the following statements: If I lose or damage an item I am responsible for the replacement cost. I understand I will be notified of overdue items on my account and will return them promptly. My library account and personal information will be kept on file at the Library. Staff will access my account and use functions such as 'My Reading History' to manage my selections. I may become ineligible for the program if circumstances change or I am unable to abide by the guidelines set forth.

Required

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