Homebound Delivery Application
Complete the form below to request home delivery of library materials.
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First and Last Name *
Phone Number *
Your Email *
Birthday (Needed to Create an Account) *
Address *
Group Residence Name (If Applicable)
ACKNOWLEDGEMENT OF PROGRAM ELIGIBILITY    The homebound service is available to anyone who is unable to get to the library because of age, disability or illness, lack of transportation, or those who do not feel comfortable using in-person services at this time. It is supported by Portage Lake District Library staff and volunteers and is offered based on volunteer availability. To be eligible for the homebound program individuals must meet the following criteria. Please check those that apply to you: *
Emergency Contact (Name, Phone, Email) *
Is your emergency contact authorized to receive information about your library account if needed?
Library Card Information (PLDL Card Number beginning with 23740)
Check this box if you do not have a library card.
Delivery Information (Our staff or volunteers will leave or pick up materials from your doorstep and will be no-contact.) Please check one of the following options: *
Homebound Delivery Program Patron Reading and Materials Preferences: To ensure a good experience in our program, we need information on what type of library materials thatyou would like to borrow. This reader profile will be kept in the Homebound delivery files and given to a Homebound Program volunteer(s). The form is the most useful resource we have in making yourmaterial selections. You may update your information at any time by informing your volunteer or bycontacting the Volunteer Coordinator at the library. The information contained in this profile and information about books sent to you is strictly confidential and will be seen only by library staff and Homebound volunteers. Check as many as you wish.
Please give us more information about your fiction or nonfiction preferences:
Please indicate here if you would prefer audiobooks and/or ebooks instead of print materials:
DVD Preferences:
Please list TV show examples:
Magazine Preferences: The library does not subscribe to all magazines. We can accommodate requestswithin what we have available on our shelves. Please list magazine titles of interest below:
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