Highland Township Library – Homebound Book Delivery - DOC

							                   Highland Township Library
            Homebound Deliver y Ser vice Application

Name:

Address:                                                  Zip code:

Phone:

City/Township to which property tax is paid:

Birthday:                                                 Sex:     M   F

Emergency Contact Name:                                   Phone:

I am unable to visit the public library due to injury, illness or disability and
would like to receive homebound service. I certify that the above
information on this form is correct and accept responsibility for those
materials borrowed on the library card issued from this application. I
accept permission for Highland Township Library personnel to use my
library card to checkout materials for me.
            Signed ______________________________
             (parent or guardian’s signature if under age18)


1. What type of fiction do you like to read? Circle all that apply.

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


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




                                                          continued on next page…
3. Is there anything which you would find offensive in a book?
       Excessive obscene language             Graphic violence
       Explicit sexual content                Alternative lifestyles
       Alcohol/drug use                       Other – please list/describe
       _________________________________________________________________
       _________________________________________________________________

4. Are you interested in non-fiction materials?
      Please circle any/all types you enjoy.

      Cookbooks                          History
      True Crime                         Religion
      Diet                               Exercise
      Art                                Scrapbooking
      Knitting                           Hunting/Fishing
      Biography                          Bestsellers
      Other – please list/describe _____________________________________
      ________________________________________________________________

5. Are you interested in receiving music CDs?
      Please circle any/all types you enjoy.

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

6. What formats would you like to receive? Circle all that apply.

     Adult & Teen materials:              Children’s materials:
      Print                                Print
      Large Print                          Magazines
      Magazines                            Book on Cassette
      Book on Cassette                     Book on CD
      Book on CD                           Media Kit
      VHS                                  VHS

7. About how many items would you like per delivery?
     1-3                       4-6
     7-9                       10-12

  Call the Highland Township Adult Activity Center at 248-887-1701 or drop this application off at
                              209 North John Street, Highland, MI 48357.