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Homebound Reading Program Application

Please correct the field(s) marked in red below:

Please fill out the Homebound Reading Program application below. Your application will be reviewed and you will be contacted by our volunteer coordinator.

 

Please note: This application is considered public record

*Required fields

Your information
 *
Your information
Are you a City of Mesa resident?
Are you a City of Mesa resident?
Does health, motility or disability permanently prevent you from coming to the library?
Does health, motility or disability permanently prevent you from coming to the library?
Do you have any family members, neighbors or friends who can run library errands on your behalf?
Do you have any family members, neighbors or friends who can run library errands on your behalf?
Do you live in a Group Home, Assisted Living or Nursing Facility?
Do you live in a Group Home, Assisted Living or Nursing Facility?
If you live in a Group Home, Assisted Living or Nursing Facility, please list:
If you live in a Group Home, Assisted Living or Nursing Facility, please list:

Please give the name of a person to be contacted if you cannot be reached for an extended period:

Please give the name of a person to be contacted if you cannot be reached for an extended period:
What format(s) would you prefer?
(check all that apply):
What format(s) would you prefer? (check all that apply):

What kind of FICTION books do you enjoy?
(check all that apply)

What kind of FICTION books do you enjoy? (check all that apply)
What kind of NON-FICTION books do you enjoy?
(check all the apply)
What kind of NON-FICTION books do you enjoy? (check all the apply)

Who are your favorite authors:

What are your favorite subjects?

I wish to enroll in the Mesa Public Library Homebound Reading Program. I have received a copy of the program’s brochure and agree to abide by its terms.

Certification of Applicant: I hereby certify that all answers to the questions on this application are true, and I understand and agree that any misstatement or omission of material facts contained in this application may disqualify me from the Homebound Reading Program.

 
 *
  1. To receive a copy of your submission, please fill out your email address below and submit.

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