Homebound Delivery Service
Residents of Jefferson Township, Wayne County, Indiana who are unable to visit the library due to a visual or physical impairment may register for this service by filling out this form. Please note that a valid library card is necessary for this service and may require the creation of a library account before service can begin.

Homebound Status is determined based on an inability to physically access the library due to visual or physical impairment, chronic illness, injury or convalescence.

Information obtained through this form is for program use only and is strictly confidential.
Basic Information
Last Name *
First Name *
Middle Initial
Street Address *
Phone Number *
Eligibility Certification
This service is for homebound individuals only. Your status as such an individual must be certified by a professional.
Eligibility Criteria *
must be certified by a Doctor of Medicine or Osteopathy, a Nurse Practitioner or Library Director.
If you are homebound because of an injury or convalescence, how long do you expect this to last?
Name of Certifying Professional *
Title of Certifying Professional *
Phone Number for Certifying Professional *
Service Preferences
What format of reading materials do you prefer? *
Check all that apply
Required
How often do you prefer delivery? *
Deliveries will be on Tuesdays
How many BOOKS would you prefer in each delivery? *
Limit of 10 TOTAL items per delivery
How many BOOKS ON CD would you prefer in each delivery? *
Limit of 10 TOTAL items per delivery
How many MAGAZINES would you prefer in each delivery? *
Limit of 10 TOTAL items per delivery
How many DVDs would you prefer in each delivery? *
Limit of 10 TOTAL items per delivery
Please let us know if you have favorite authors or specific interests. *
Interest Profile
Fiction Interests
Check all that apply
Nonfiction Interests
Check all that apply
Please add more information for options that asked for specification.
Movies
Check all that apply
Submit
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This form was created inside of Hagerstown Jefferson Township Library.