Outreach Services
Application for Service

Name:

Date of Birth:

Address:

City:

State:

Zip:

Phone:

Facility Name:

Emergency Contact Name:

Emergency Contact Phone:

Reason for requesting special delivery:
Physically Disabled          Illness

If other, please explain  Explanation

If you reside in your own home, do you have a friend or family member who would be able to deliver your books?  Yes     No

If yes, please give name: 

Relationship of person delivering books: 

Phone of person delivering books: 

Please select your reading interests from the following categories.  Check all that apply.  You may also make specific requests.

Fiction Choices (Check as many as apply.)

Nonfiction Choices (Check as many as apply.)

Comments:
Enter comments

Type of books needed:

Please check here if you do NOT want books that contain:

Number of books you can read in one month: