Morley Library Homebound Application

 

Name: _________________________________________
Date: __________________________________________

Address: _______________________________________
Phone: _________________________________________

If applicable: Assisted living or Nursing Home facility _____________________

Homebound service is needed because ____________________________

For how long? ____________________

 

 

Reader Preferences

(Please circle all categories that apply.)

 

Fiction:

Adventure                                        Horror                                               Sci-Fi / Fantasy

Animal Stories                                 Humor                                              Spy/War Stories

Bestsellers                                      Love Stories                                    Westerns

Classics                                           Mysteries                                         Techno-thrillers

Historical: American / Foreign        Romantic Suspense

 

Nonfiction:

Adventure                                        History: American / Foreign            Philosophy

African American                             Hobbies/How to Books________ Plays

Animals                                            Homemaking                                   Politics / Gov’t    

Bestsellers                                      Human Sexuality                              Psychology

Biography                                         Humor                                              Religion

Business                                          Music                                                Science

Current Events                                 Nature                                               Sports

Ethnic Interests___________       Occult                                               Travel & Leisure

Fine Arts__________                    Ohio Interest                                    TV/Film

Health/Disabilities__________      Other___________                        War

 

 

Media Preferences:  Please circle which formats and indicate how many of each you would like to receive each month.

 

Books: ___ hardcover / paperback / large print            Spoken CD: ___

 

Magazines: ___ Preferred titles: _____________  _____________  _____________

 

Music CDs: ___ Preferred artists: _____________  _____________  _____________

 

Nonfiction videocassette/DVD ___         Feature films on DVD (Limit 2)___

 

Favorite Authors: _______________ ________________ _________________

 

Please circle if you would NOT accept items that contain any of the following:

          Explicit sex                             Rough Language                             Violence

 

 

 

By signing this application, I agree to accept financial responsibility for damaged or lost library materials.

 

 

Signature: ________________________________________ Date: __________

 

 

If you are signing on behalf of the person receiving homebound delivery, please indicate relationship.

 

___________________________________________

 

 

If you are signing for an individual in a nursing home or other facility, please indicate your position.

 * Please note that the nursing home, assisted living facility or other institution that requests homebound delivery on behalf of a resident, accepts financial responsibility for all library material

that may be lost or damaged.

 

Facility:_________________________________________  Position:_________________________

 

 

 

Please return the completed application to:

Morley Library

184 Phelps St.

Painesville, OH 44077

ATTN: Homebound Services

 

Text Box:  

      

            Office Use Only –

               Copy to:

               Homebound Circulation Staff ___________          Date ______

                Homebound Delivery Staff _____________         Date______

                Homebound Selector __________________     Date ______

                Date of first delivery ________