SCDL Homebound Services Application - Stark Library · SCDL Homebound Services Application...
Transcript of SCDL Homebound Services Application - Stark Library · SCDL Homebound Services Application...
SCDL Homebound Services Application
Homebound Service is a specialized library service that offers delivery of library materials to the homebound customer who is temporarily or permanently not able to visit the library due to a disability, vision impairment, illness, or impaired driving ability.
Please take a few minutes to answer the following questions and return to the address above.
Name (Last, First)________________________________________Phone Number_____________________
Address_________________________________________ City ______________________ Zip___________
Date_____________________________
1. Are you permanently/temporarily homebound? Permanently______ Temporarily______
2. If you are temporarily homebound, how long do you anticipate using this service?
1-6 months______ 6 months or longer______
3. Is there anyone living in your household willing to pick up library materials for you?
Yes______ No______
4. Do you reside in Stark County? Yes______ No______
5. What school district do you reside in? _______________________________________
6. What special types of materials are required for you to best use library resources?(Example: Large print, books on CD , audio, other)
7. I give Stark County District Library permission to contact the person identified below if Stark CountyDistrict Library is unable to reach me. Yes______ No______
Name of Contact Person____________________________ Emergency phone number_______________
Patron Signature________________________________________________________
Return completed form to the:Stark County District Library / 715 Market Ave. N / Canton, Ohio 44702
Outreach Services / 330.458.2827
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