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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.

Last/First/M.I.
Street, Apt #, City, State, Zip Code
(***) ***-****
If you do not already have a library card, you will also need to complete and return a Library Card Application.
MM/DD/YYYY
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.