Homebound Form

Homebound Service
Community Outreach
Monroe County Public Library
303 E. Kirkwood Ave.
Bloomington, IN 47408
(812) 349-3050 ext. 2058

First name:
Last name:
Age:	Sex: Male Female
Address:
City:	Zip:
Barcode:	(optional)
Phone:
Email:
Birthday:	Year:
Physical Limitations:
Emergency Contact:
Deliveries are made monthly. Please write down how many items you want delivered in each category each month. (We will keep a list of items we deliver to you to avoid duplicates. Please let us know if you perfer that we do not keep track of what you borrow.)
Number per month	Category
	Large print books
	Regular print books
	Magazines
Types of magazine:
	Books on CD
	Books on cassette
	CDs
Types of music:
	DVDs
Types of DVD:
	Videocassettes
Types of video:
Check areas of interest:

modern novel	poetry	travel/U.S.
historical novel	art history	travel/other
classics	Indiana history	psychology/self-help
inspirational fiction	U.S. history	philosophy
detectives	history/other	health
adventures	science fiction	humor
westerns	religious nonfiction	current events
romance	politics and government	plays
Harlequin romance	children's books	sports
biography—subjects:
science—type:
handicrafts—type:
other—(specify):
Are there any areas in which you definitely have no interest?
Are there any subject matters offensive to you?
Please list and favorite authors, movies, and music.
Please note other reading interests.
Do you have someone who is willing and able to pick up materials at the library for you on a regular basis? (This is NOT required for service.)
Comments:

COMMUNITY OUTREACH
www.mcpl.info/outreach
812-349-3050, ext. 2058