SCDL Homebound Services Application

Homebound Service is a specialized library service that offers delivery of library materials to the homebound customer who is temporarily or permanently not able to visit the library due to a disability, vision impairment, illness, or impaired driving ability.

Please take a few minutes to answer the following questions and return to the address above.

Name (Last, First)________________________________________Phone Number_____________________

Address_________________________________________ City ______________________ Zip___________

Date_____________________________

1. Are you permanently/temporarily homebound? Permanently______ Temporarily______

2. If you are temporarily homebound, how long do you anticipate using this service?

1-6 months______ 6 months or longer______

3. Is there anyone living in your household willing to pick up library materials for you?

Yes______ No______

4. Do you reside in Stark County? Yes______ No______

5. What school district do you reside in? _______________________________________

6. What special types of materials are required for you to best use library resources?(Example: Large print, books on CD , audio, other)

7. I give Stark County District Library permission to contact the person identified below if Stark CountyDistrict Library is unable to reach me. Yes______ No______

Name of Contact Person____________________________ Emergency phone number_______________

Patron Signature________________________________________________________

Return completed form to the:Stark County District Library / 715 Market Ave. N / Canton, Ohio 44702

Outreach Services / 330.458.2827

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