CCPLS LogoCampbell County Public Library System
Gillette and Wright, Wyoming

Homebound Application
Name: *Required
Address:
Daytime Phone: * Required
Evening Phone:
Library Card #
Family/Care Giver Contact:
Family/Care Giver Phone:
Preferred visitation time: Mornings:
Afternoons
Days you are available: Monday    Tuesday    Wednesday    Thursday
Reason for homebound application:

Have you received this service from us before?

    

If yes, when?

Do you have family members who can deliver materials to you?

     

References: Please supply a friend or family member other than stated above that can be used as a reference.
Name:      Phone:
Number of books to be delivered each visit?
What type of book do you prefer? Hardback books Paperback books No Preference
What size print do you prefer? Regular Print Large Print No Preference
Subject/Genre Interests:

Books on CD Books on Tape DVDs Videos

General Fiction Christian Fiction Mystery
Romance Science Fiction Westerns

Biographies Cookbooks Crafts/Sewing
Gardening Health/Medical History

Children's Books Picture Books

Other interests:

Please check the boxes next to each statement to signify your agreement, which will serve as your electronic signature.

You must mark your agreement to both statements for your request to be processed.

This is an expression of interest in receiving homebound services for myself or a family member. I understand this inquiry will be reviewed by a panel of library personnel regarding eligibility for homebound services and this decision will determine any and all program visitation.

I understand that this program is limited to residents within Campbell County who are homebound due to illness, disability or the aging process.

If you have any questions, contact or visit your local library during normal service hours.

 
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Campbell County Public Library System
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