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Homebound Application

Interested in becoming a homebound patron? Fill out the form below and our Homebound Delivery Coordinator will contact you shortly.

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Do you have a library card with us?(Required)

Yes

No

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email

Phone

Best day to delivery(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Best time for delivery(Required)

8am-10am

10am-12pm

12pm-2pm

2pm-4pm

4pm-6pm

Materials you would like (Check all that apply)(Required)

Regular print books

Large print books

Books on CD

Magazines

Categories (Check all that apply)(Required)

Romance

Mystery

Suspense

Western

Fantasy

Science Fiction

Current bestsellers

Historical Fiction

History

Biography

Current events

Politics

Music

Religion

Fine arts

Health

Travel

Gardening

Cooking

Crafts/hobbies

Favorite authors/Favorite books (Please provide information that will help select materials that you will like)(Required)

May we keep a list of your materials to help avoid duplication?(Required)

Yes

No

Emergency contact name:(Required)

Emergency contact phone number:(Required)

Emergency contact relationship(Required)

Δ

32 Sheboygan St
Fond du Lac, WI 54935

reference@fdlpl.org
920-929-7080

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