Homebound Delivery Form - Ascension Parish Library

Homebound Delivery Request

Please fill out this form for more information, to register for the service, or to recommend a friend or family member for the service.

Title

Full Name Last/First/M.I.

Address Street, Apt #, City, State, Zip Code

Phone (***) ***-****

Best time of day to call

Ascension Parish Library Card Number If you do not already have a library card, you will also need to complete and return a Library Card Application.

Date of Birth MM/DD/YYYY

Do you have a computer with internet access and an email account?

If yes, what is your email address?

Which delivery method would you prefer?

Are you applying for temporary homebound status?

If yes, how long will you need this service?

Please provide the name and phone number of someone we can contact if you cannot be reached for an extended period of time:

I have read and agree to the following: I am applying for the privilege of borrowing library materials from Ascension Parish Library, Homebound Delivery Service. I give permission for APL staff to use my library card number to check out materials on my behalf. I agree that a record of library materials I check out and my reading interests may be kept, with the understanding that my reading history and interests will be kept confidential. I declare that I am homebound and unable to go to Ascension Parish Library due to health, mobility, advanced age, visual impairment, blindness, physical disability, permanent or temporary incapacity.