Patron Information
Name __________________________________ Birthdate _____________________________
Address ________________________________________________________________________
City __________________________________ Zip __________________________________
Facility ______________________________ Room Number __________________________
Phone __________________________________ Email ________________________________
Library Card Number ___________________________________________________________
(If you don't have one, we will obtain one for you)
Check Your Choices
Reason you are unable to visit the library:
☐ Illness
☐ Disability
☐ Visual Impairment
☐ Other
How long do you need service?
☐ Winter Only
☐ 2-6 Months
☐ Ongoing
Type of delivery requested:
☐ Family Member ☐ Books by Mail
Door Drop Delivery
Where should the delivery bag be dropped off / picked up?
_________________________________________________________________
Waiver
☐ I grant Medina County District Library permission to keep a printed record/list of my borrowed items, requests, and preferences for the purposes of selecting materials. This information will be used only by the Outreach Services staff. The staff maintains the privacy and confidentiality of every library member.
☐ I do not grant Medina County District Library permission to keep a printed record/list of my borrowed items and preferences. Please note: It is not required to grant permission in order to receive library services.
Signature _________________________________________ Date ______________
Or verbal consent given to _______________________________________________