Application for Residential Services | Medina County District Library

Name

Street Address / P.O. Box

Apt. Number

Facility

Room

City

Zip Code

Birthdate

Library Card #

Phone Number

Preferred method of communication

Length of service requested

Preferred Method of Delivery

Emergency Contact Name

I certify that I am unable to get to the library or bookmobile regularly and will notify staff if my circumstances change.

Yes

Contact Information for Person Completing Form if not the Member

Contact Name

Relationship to Patron

Contact Phone Number

Contact Email