Outreach Services Form
Need materials delivered to you through our Care Facility Delivery, Homebound Services, or Books By Mail service? Complete this form and let us do the work!
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have a Geauga County Public Library card?
*
Yes
No
Library Card Number
Acknowledgement of Program Eligibility:
*
I live in Geauga County.
I am unable to visit the library due to disability or extended illness.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you reside in a care facility, what facility are you located at?
Phone Number
*
Format: (000) 000-0000.
Email
*
If you don't have an email address, please enter Outreach@geaugalibrary.net
How do you want to receive information about this service?
*
Phone
Email
What service are you applying for:
*
Care Facility Delivery
Homebound Services
Books By Mail
I'd like to discuss what options best suits my needs with the Library's Outreach Librarian.
Preference for requesting materials:
*
I am able to use the Library’s digital catalog to select and place materials on hold.
I have a computer or tablet, but I would like to receive training to learn how to use the Library's digital catalog and services.
I do not feel comfortable accessing the Library's digital catalog or do not have access to a computer or tablet. I need a Library staff member to place holds for me; I will provide them with the specific items I would like.
I do not feel comfortable accessing the Library's digital catalog or do not have access to a computer or tablet. I would prefer a Library staff member selects materials for me based on the criteria I provide them.
What materials and format(s) do you prefer?
*
Print Books
Paperback
Large Print
Audiobooks (CD)
Audiobooks (Playaway)
DVD
Blu-Ray
Music CD
Other
Explicit Language
*
Any
Some
None
Violence
*
Any
Some
None
Sex
*
Any
Some
None
Can you hold materials weight more than 3 pounds?
*
Yes
No
Preferred Genres
What are your favorite books and movies?
Who are your favorite authors?
How many items would you like per delivery?
*
Are you interested in using the Libby or Hoopla app to access materials digitally?
Yes
No
Would you like to keep track of your checkout history through your library account?
Yes
No
Emergency Contact Information
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
If you don't have an email address, please enter Outreach@geaugalibrary.net
Relationship to patron?
*
Do you give your emergency contact authorization to receive information about your library account (if needed)?
*
Yes
No
Submit
Should be Empty: