Outreach Patron Profile
Tomahawk Public Library Form
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Name (Last) *
Name (First) *
Name (Middle) *
Organization
Address (Street, City, State, Zip Code) *
Phone *
Email
Emergency Contact *
Emergency Contact Phone *
I would like outreach delivery for
Clear selection
I would like to receive _____ (number of) Books per visit.
I would like to receive _____ (number of) Audiobooks on CD per visit.
Clear selection
I would like to receive _____ (number of) movies on DVD per visit.
Clear selection
What type of movies:
I would like to receive _____ (number of) music CDs per visit.
Clear selection
What type of music?
I would like to receive _____ (number of) Magazines per visit.
What title(s) and/ or genre of magazines?
I would like to recieve_____ (number of) Coloring Pages?
I would like to recieve ____(number of) Crossword Pages?
I would like to recieve ____(number of) Sudoku Puzzles Pages?
Disclaimer and Signature
I verify that I am unable to come to the library due to disability, extended illness, or other incapacitating circumstances. I give permission for the Tomahawk Public Library to keep a record of the library materials sent to me in order to avoid duplication. This information will be kept confidential within the department. Services can begin after verification of library card ownership.
Signature *
Date
MM
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