HomeWord Bound Form

Qualification for HomeWord Bound Service:

I am a resident of Deschutes County, Oregon

At least one of these must apply: *

Short-term disability
Long-term disability
Illness which confines individual to their home
75 years or older

Name *

Mailing Address *

City, State, Zip *

Physical Address (if different)

Home Phone (so library staff can contact you) *

Best day and time to call you

Email *

Gender

Male
Female

Birth date *

Do you reside in a residential care facility or an apartment complex?

yes
no

If "yes," facility name

Name of person helping fill out this form

Should library staff contact the person helping to fill out this form about applicant's reading preferences?

yes
no

If yes, phone number

HomeWord Bound