Adults_Request for Home Delivery

    Request for Home Delivery

    Our experienced staff will be glad to consider your request for home delivery! Please fill out the form below, and we will be in touch with you shortly. You can also download and print out the application via this link if you want to fill it out by hand.

    Name (required)

    Address (required)

    City & ZIP Code(required)

    Date of Birth (required)

    Telephone (required)

    Email

    Do you already have a library card in Waukesha or Jefferson County?

    YesNo

    If yes, then please provide your Library Card Number, otherwise skip to Emergency Contact Information

    Emergency Contact Information

    Name

    Telephone

    Email

    Can we discuss your account with this person?

    YesNo

    Responsibilities of Program Participant

    (please type your initials to show agreement)

    I declare that I am unable to independently use the Library due to an ongoing health condition. (Note: You do not need to disclose the nature of your condition.)

    I agree to a background check. (Note: Leave blank to opt out)

    I understand that I am responsible for Library materials checked out on my card and for payment of lost or damaged items.

    I understand that the Library will maintain a history of my checkouts.

    I understand materials will be delivered to and picked up from my home, but staff/volunteers will not enter my home.

    Typing your name will serve as a signature for this form

    Signature: Date:

    What are your reading interests? (Check all that apply)

    RomanceAmishReligionMysteryShort StoriesSelf HelpSciFiBiographiesScienceWesternsPoetryHistoryClassic LiteratureBiographiesFine ArtsChristian fictionFantasyTravel
    Other

    Who are some of your favorite authors? Please limit yourself to 3 or 4

    Please check any subjects that do not interest you? (Check all the apply)*

    SexDeathViolenceFoul LanguageReligionAddictionWarPolitics

    Other
    * We will do our best to avoid subjects that aren’t of interest to you, but we cannot read/watch all materials provided. If you receive an item that you don’t enjoy, please just let us know so we can avoid providing you with similar materials going forward.

    What formats and types of materials would you like? (Check all that apply)

    Large print booksDVDsPlayawaysRegular print booksBlu RayMusic CDsPaperbackAudiobooks on CDMagazines

    How many materials would you like per delivery?