Homebound Delivery Application

Eligible patrons may complete the Homebound Delivery Service application below, or you may request a print form. To request a print form or for more information about Homebound Delivery, contact LaDonna at 543-7675 ext. 2552 or e-mail [email protected].

Name:*
First Last
Address:*
Street Address Address Line 2 City State ZIP Code
Phone Number:*
E-mail:
Emergency Contact Name:*
First Last
Emergency Contact Phone Number:*
Eligibility Criteria: (choose all that apply)*
- Medical
- Transportation (Ages 65+ only)
- Other
If other, please explain:
Eligibility Certification
Who will be providing eligibility certification?*
- a caregiver
- a medical professional
- a social worker
- clergy
Name of the individual providing certification. You will need to provide documentation and/or a signature from this individual during the initial visit.*
First Name Last Name
Homebound Delivery Waiver
I understand that I assume financial responsibility for lost or damaged library materials. I also understand I will become ineligible for this service if I do not return library materials.

By completing this waiver, I grant BCPL permission to use my library card to check out materials on my behalf and to maintain a reading history log on my account.
Name:*
First Last
Date:*
MM slash DD slash YYYY
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Homebound Delivery Waiver