Homebound Delivery Application Name (required) Street Address (required) City (required) State (required) Zip (required) Phone (required) Email Please provide contact information for someone we may call if you cannot be reached for an extended period. Name (required) Phone (required) All recipients of home delivery of Bethel Library materials must be residents of Bethel. Recipients must not have anyone who can pick up or deliver materials to them on a regular basis and must meet one or more of the following required conditions. Check all that apply (required) Physical or mental disability that prevents me from coming to the Library on my ownIllness with minimum recovery period of 2 monthsNon-driver age 65 or older Please specify reference, for example Senior Center Director, Social Services Director, medical doctor, etc. May not be a member of applicant’s family. Referred by (required) Overdue fines are not charged for materials delivered under this program. However, replacement costs will be charged for materials lost and/or damaged while in your care. By submitting this form, you agree that you will pay for library materials lost or damaged while in your care, that you have received copies of the Home Delivery of Library Materials Policy, Procedures and Code of Conduct, and that you agree to abide by them.