Hamburg Township Library Homebound Application

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Hamburg Township Library's Homebound Connection

10411 Merrill Road, P.O. Box 247, Hamburg, MI 48139
Phone: (810) 231-1771    Fax: (810) 231-1520    Email: connect@hamburglibrary.org
Requested Delivery Day (circle): Monday   Tuesday   Wednesday   Thursday   Friday
Time Block (circle): 9:00 a.m.-noon   noon to 4:00 p.m.   Other
Name: Library Card #:
Address: Apt.:
City: Zip Code:
Phone: ( ) Email:

Application to be completed in the home

Individual has a permanent condition that prohibits them from safely visiting the library (including giving up driving status).
Individual has a temporary condition (medical leave due to surgery, etc.) that prohibits them from safely visiting the library for at least 6 weeks.
Expected recovery date is:
I give the library permission to contact me by email regarding my library Homebound Connection account.
Please contact me regarding the Library for the Blind and Physically Handicapped (LBPH) regarding services that may be available to me.

I understand that I assume financial responsibility for the materials I receive and will pay any applicable charges for lost or damaged materials to maintain lending services.

    
Applicant Signature                            Date

Which library service would you like? Check one (1)

Monthly delivery
Flexible check-out. The person(s) listed below are authorized to pick up books for me (limit to ten (10) items per account).
Name:
Phone:
Name:
Phone:

How would you like materials selected for you? Check one (1)

Request Only: I want to make my own selections and call/email the library when I want items delivered.
Readers' Advisory: I want the library staff to make selections for me based on the subject and author preferences I have indicated below.

1. What type of materials and how many would you like to receive?

I would like print books. How many?
I read only Large Print books. How many?
I prefer Large Print, but will accept regular print to fill my request.
I can't hold heavy books. Do not send books over pages.
I want paperback books: Only    Never
I prefer audio books: CD format    MP3 format CD
How many?
I would like magazines. How Many?
Magazine title(s)/genre(s):

2. What type of fiction do you like to read? (Circle all that apply)

Adventure      Bestseller
Christian Fiction      Crime
Fantasy      Historical Fiction
Horror      Humor
Legal Thriller      Mystery
Romance      Science Fiction
Western

3. Please list any authors or books which you have read and enjoyed.

4. Is there anything which you find offensive in a book? (Circle all that apply)

Alcohol/drug use      Alternative lifestyle
Explicit sexual content      Excessive obscene language
Graphic Violence
Other- Please list/describe:

5. Are you interested in non-fiction materials? (Circle all that apply)

Art      Bestsellers
Biography      Cookbooks
Diet      Exercise
History      Hunting/Fishing
Humor      Knitting
True Crime      Religion
Scrapbooking      Sports
Travel      War
Other–Please list/describe:

6. Are you interested in receiving music CDs? (Circle all that apply)

Pop/Rock      Easy Listening
Folk      World
Classical/Opera      Country
Jazz      Soundtrack (movies & musicals)
Children's Music      Religious

7. Are you interested in movies (DVD)? (Circle all that apply)

Action      Adventure
Comedy      Crime and Gangster
Drama      Epics/Historical
Horror      Musicals/Drama
Science Fiction      War
Other (please list/describe):
Hamburg Township Library retains the right to refuse service in the event of unsafe conditions.

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