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2. Full Name*
4. Physical Address*
5. Mailing Address*
7. Phone Number*
8. Library Card Number*
10. Family / Care Giver Contact*
11. Family / Care Giver Phone*
13. Preferred Visitation Time*
    -- Select One --MorningsAfternoons
14. Days You Are Available*
    -- Select One --MondaysTuesdaysWednesdaysThursdays
16. Have you received this service from us before?*
    -- Select One --YesNo
17. If yes, when?
19. Do you have a family member who can deliver materials to you?*
    -- Select One --YesNo
20. Please supply a friend or family member other than stated above that can be used as a reference.
24. Number of books to be delivered each visit
25. What type of book do you prefer?
    -- Select One --PaperbacksHardbacksNo preference
27. What size print do you prefer?
    -- Select One --Regular printLarge printNo preference
29. Subject / Genre Interests

    1. Books on CD
    2. DVD
    3. General fiction
    4. Christian fiction
    5. Mystery
    6. Romance

    1. Science fiction
    2. Westerns
    3. Biographies
    4. Cookbooks
    5. Crafts / sewing

    1. Gardening
    2. Health / medical
    3. History
    4. Children's books
    5. Picture books
33. Agreement Statement*

    This is an expression of interest in receiving Outreach services for myself or a family member. I understand this inquiry will be reviewed by a panel of library personnel regarding eligibility for Outreach services and this decision will determine any and all visitation.
    
    I understand that this program is limited to residents within Campbell County who are home bound due to illness, disability or the aging process.
    
    Please check the box to signify your agreement, which will serve as your electronic signature. You must mark your agreement for your request to be processed.

    1. Yes, I agree
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field