Homebound Services Application

Current Contact Information
Reading Preferences
Formats
Complete

Date of Request:

First Name

Last Name

Address

Address 2 (optional)

City/Town

State

ZIP

Telephone:

Email:

Library Card Barcode:

Emergency Contact:

List the name and phone number.

I certify that I am unable to visit the library due to a temporary or permanent illness or disability. I give permission for a librarian to use my library card number in the computer system to check out library materials for me.

Signature:

Sign above