At Home service application

Is this address a senior residence, nursing home or assisted living?

ex. 952-000-0000
Are you unable to visit a library because of:

How long do you need service:

How do you prefer to receive materials:

Please provide both name and phone number
Do you have a library card?

What format of reading materials do you prefer?

(check as many as apply)
How did you hear about At-Home Service?

Emergency contact information