May 2, 2000
Application for Outreach ServicesSt. Charles Public LibraryOne S. 6th Ave., St. Charles, IL 60174Phone: 630-584-0076, ext. 219, FAX: 630-584-3448Applicant’s Name: ______________________________________________________Street Address: ________________________________________________________Home Phone: ______________________Family Contact: Name:_____________________ Phone:___________________Eligibility & CertificationPlease check the reason(s) you require Outreach Services:□ Visual impairment, to degree that would prevent obtaining a driver’s license □ Physical disability, hampering ability to get in, out, and around the Library □ Recovery from surgery or injury □ Ordered bed rest□ Other - please explain: _______________________________________________I certify that the above is true and that I am a resident of the St. Charles Public Library District. I promise to abide by the St. Charles Library Rules and Regulations and accept responsibility for materials loaned to me. Name:_____________________Signature:__________________________Date:_____ - - - - - - - - - - - - - - - - - - For Office Use Only - - - - - - - - - - - - - - - - - - - - -Date of Outreach Orientation: __________________Staff Members Present: ____________________ ________________________Signature of Outreach Services Librarian: _____________________________Reading InterestsHelp us choose titles that you’ll enjoy:1. Indicate the kind of books you would like to read (check all that apply.)□ Romance□ Mystery/Detective □ Family Saga □Historical□ Biography/Memoir □ Romantic Suspense □ Paranormal Romance □ Medical Thriller□ Spy □ Gentle Read□ Christian □ Legal Thriller □ Western □ Adventure □ Horror □ Fantasy □ Science Fiction □ Vampires/Zombies□ Other: ______________________________2. Check the items you would find objectionable in a book.□ Extreme Violence □ Explicit Sexuality □ Graphic Language□ Other: ______________________________3. Check the book format you prefer:□ Regular Print Books □ Large Print Books □ Audiobooks □ eBooks□ eAudiobooks4. List your favorite authors:______________________________ ______________________________ ______________________________ ______________________________ 5. List your favorite books:______________________________ ______________________________ ______________________________ ______________________________ ................
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