Home delivery application

Home delivery application
Our Home Delivery Service offers delivery and pick-up of materials throughout Lucas County to people who are physically unable to visit a library due to a medical reason. We’ll select materials based upon your general interests or requests and bring them to your door every four weeks.
Completed
I am eligible for this service because I am: (Please check all that apply)

unable to use a library facility due to a medical reason.unable to travel to a library due to a medical reason.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email
example@example.com
Date of Birth:*

MonthDayYear
Contact Name & Phone Number: (If different than patron)
Alternate Contact Name

First NameLast Name
Alternate Phone Number
Alternate Email
example@example.com
Do you have a library card?

YesNo
I am eligible for this service because I am: (Please check all that apply)

unable to use a library facility.unable to travel to a library.
Please explain:
Would you like the material in the following format(s)? (Please check all that apply.)

Standard Print BooksLarge Print BooksMoviesAudio BooksMusic
Any special instructions or comments:
After submitting this form, a librarian will contact you to discuss further details about Home Delivery Service.

Call us at 419.214.4663 for help.
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