Application for Home Library Service

APPLICATION FOR HOME LIBRARY SERVICE

I wish to apply for membership of the Home Library Service provided by Libraries ACT. Due to age, a disability of a medical condition, I am unable to come to the library and/or cannot carry books home. I agree to conform to the conditions laid down by the library, and to pay any charges incurred for lost of damaged material.

I understand that the library will ring me so that arrangements can be made, and that any personal information I give to the library will be kept strictly private.

Libraries ACT Conditions of Membership

I apply for membership of Libraries ACT for myself/ my child.

I agree to:

·  Return library material by the due date

·  Inform the library of changes to my personal details

·  Pay for lost, damaged or stolen library materials plus any administrative fees

·  Pay any overdue fees charged

·  Be responsible for ALL items borrowed on my or my child’s card

I am aware that

·  My membership will be suspended if there are excessive overdue fees of I have items overdue for fourteen days or more

·  It is the responsibility of parent/guardians, not library staff, to determine what materials are suitable for my child/ren to borrow from the library and what my child/ren access on the Internet

Having read the conditions, I agree to conform to them.

Full name ______

Date of birth ______

Address ______

Suburb ______Postcode ______

Phone (home) ______(mobile) ______

Email ______

Signature ______Date ______

See page 2 for referral details – both forms must be completed and returned to the library.
Reasons for application (tick one)

q  A short term illness, e.g. recuperating after an operation or suffering from a broken bone. Approximate time service will be required ______

q  Chronic or serious illness or disability that prevents me from visiting a library.

q  Other (please specify) ______

REFERRAL

I nominate ______as a person requiring the services of the Home Library Service for reason/s listed above.

Practitioner’s name ______

Organisation/occupation ______

Address ______

Suburb ______Postcode ______

Phone (work) ______

Email ______

Signature ______Date ______

·  Persons able to sign referral: Medical practitioner, activities officer (nursing homes), community nurse, community carer, Canberra Blind Society.

·  A phone referral to 6207 5748 from one of the above is also acceptable.

Please return forms to:

MAIL
Home Library Service
c/- Belconnen Library
12 Chandler Street
Belconnen ACT 2617 / FAX
6207 7400 / EMAIL
(scanned completed form)