Hennepin County Library - At Home Service Application

at home service application

At Home Service Application

First Name:

Last Name:

Middle Initial:

Street:

Apt:

City:

Zip:

Birthdate:

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

Yes
No

If yes, which one?

Telephone:

ex. 952-000-0000

Email:

Are you unable to visit a library because of:

Illness
Visual Impairment
Disability
Other

How long do you need service:

2-6 months
Winter only
Ongoing

How do you prefer to receive materials:

By Mail (postage is paid both ways)
By Volunteer

If volunteer, do you know someone who is willing to bring you materials?

Name
Phone

Do you have a library card?

Yes
No

Library Card Number:

What format of reading materials do you prefer?
(check as many as apply)

Large print
Regular print
Books on Compact Disc
DVD

To help us choose materials for you, please tell us some of your favorite authors, titles, or subjects:

How did you hear about At-Home Service?

Friend
Relative
Hennepin County Library staff
Human services agency
Other

Please provide the following emergency contact information:

Signature:

At Home
612-543-8850

Corrections
612-543-8852

Senior Housing
612-543-8858

VOLUNTEER

Deliver books to patron's homes, assist at senior assisted living facilities, or donate magazines for correctional facilities.

To volunteer, complete an online application or call the Volunteer Coordinator at 612-543-8545.

RESOURCES

Accessibility
Eliminating barriers that make it difficult for people with disabilities to use library services.

Life Stages & Caregiving
Information resources of particular interest to seniors and those who care for older adults.

Savvy Senior
Weekly column with advice and valuable information on a variety of topics.