Homebound Delivery Application
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Participant
Name:
Address:
Phone:
Email:
Emergency Contact Person
Emergency Contact Name:
Phone:
Email:
Relationship:
Authorized to get information about the account?
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Library Card Information:
I have a library card. My number is:
I don't have a library card yet. Please contact me about setting up a card.
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I am unable to easily come to the library because of (check one):
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Preferred Delivery Day
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By clicking below, I signify that I understand that I am responsible for materials delivered to me through the homebound program.
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Reading Interests
Fiction (check all that apply):
Nonfiction (check all that apply):
My favorite authors are:
Formats/Types of Materials Requested (check all that apply):
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