Application for Homebound Services

What is the reason for requesting delivery of library materials?

I confirm that I am unable to visit my local library for a minimum of 3 months due to one or more reasons below. Check all that apply.

I live in a nursing home or a residential care facility.

I have a medical condition, disability, or am recovering from a medical procedure or illness.

I am unable to travel to my local library due to age or mobility concerns.

My reason isn’t reflected in the available options above. Please contact me to discuss in further detail.

I confirm that I am unable to visit my local library for a minimum of 3 months due to one or more reasons below. *

Your contact information

First name *

Last name *

Address *

Postal code *

Facility/Building name (if applicable)

Room/Bed# (if applicable)

Special delivery instructions (ex: Ringer number)

Telephone *

Are you currently an Ottawa Public Library cardholder?

Yes

Unsure

Are you currently an Ottawa Public Library cardholder?

Library card number

Do you have access to a vehicle?

Yes

Do you have access to a vehicle? *

Do you have someone available to pick up library materials?

Yes

Do you have someone available to pick up library materials? *

Alternate contact

Is there an individual or organization whom we can contact if we cannot reach you directly, such as a friend, family member, or facility staff? Please provide their contact information below:

Full name

Relationship to applicant

Telephone

The personal information requested for your library card is collected under the authority of the Public Libraries Act. The information collected will be used in the day-to-day operations of the library.

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