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Homebound Service Application

Community Outreach
Monroe County Public Library
303 E. Kirkwood Ave.
Bloomington, IN 47408
(812) 349-3050 ext. 2058

PATRON PROFILE SHEET

First Name: *

Last name: *

Age: *

Sex: *

Male

Female

Address: *

City: *

Zip: *

Barcode:

Phone: * (xxx) xxx-xxxx

Email:

Birthday Month: *

Day: *

Year: *

Emergency Contact Name: *

Emergency Contact Phone #: * (xxx) xxx-xxxx

Physical Limitations: *

Deliveries are made monthly. Please indicate how many items you want delivered in each category each month. (We will keep a list of items we deliver to you to avoid duplicates. Please let us know if you prefer that we do not keep track of what you borrow.)

Large print books: How many?

Regular print books: How many?

Magazines: How many?

Types of magazine:

Books on CD: How many?

Music CDs: How many?

Types of music:

DVDs: How many?

Types of DVD:

Areas of interest:

Check all that apply: *

modern novel

historical novel

classics

inspirational fiction

detectives

adventures

westerns

romance - mild

romance - wild

non-fiction

non-fiction areas of interest:

Are there any areas in which you definitely have no interest?

Are there any subject matters offensive to you?

Please list any favorite authors, movies, and music:

Please note other reading interests:

Do you have someone who is willing and able to pick up materials at the library for you on a regular basis? (This is NOT required for service) :

Comments:

COMMUNITY OUTREACH
www.mcpl.info/outreach
812-349-3050, ext. 2058

Homebound Service Volunteer Form [1]

Updated February 23, 2012

Links:
[1] http://mcpl.info/webform/homebound-service-volunteer-form
[2] http://mcpl.info/print/print/outreach/homebound-service-application
[3] http://mcpl.info/printmail/print/outreach/homebound-service-application
[4] http://mcpl.info/printpdf/print/outreach/homebound-service-application