Words on Wheels Application Please ensure patron meets eligibility requirements prior to submitting this application. This service is for individuals and groups of all ages, particularly those who are unable to visit the library for an extended period of time due to age, disability, or long-term illness. Lack of transportation does not qualify a patron for this service.Patron Name* First Last Preferred Phone Number*Alternate Phone NumberDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Facility Name (if applicable) Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I have a Mesa County Libraries Card* Yes No Library Card Number Emergency ContactEmergency Contact Name* First Last Emergency Contact Phone*Is your Emergency Contact authorized to receive information about your library account if needed?* Yes No Acknowledgement of Program EligibilityIndividuals and groups of all ages, particularly those who are unable to visit the library for an extended period of time due to age, disability, or long-term illness, are eligible for this service. Lack of transportation does not qualify someone for this service.Please check all that apply to you:* I live in Mesa County I am unable to visit the library due to age, disability, or extended illness Words on Wheels Program InformationDeliveries are made during regular intervals that are subject to change but generally happen every two weeks. You will be given prior notice if there are changes to the delivery schedule, but delivery routes are currently run every Monday through Friday (except during holidays or when staff are sick or on vacation). We deliver regular and large print books, fiction and nonfiction, books on CD, playaways, magazines, and DVDs. Words on Wheels patrons may also use our e-resources including eBooks and eAudiobooks, eMagazines, and Kanopy, our movie streaming service. Please fill out the questions below regarding the type and amount of items you would like to receive with each delivery. Share with us your selection abilities:* I am able to use the library's online catalog to select and put materials on hold. I would like to receive training to learn how to use the library's online catalog and services and to put materials on hold. I have a computer or tablet. I do not feel comfortable accessing the online catalog and/or do not have access to a computer or tablet and need a library staff member or volunteer to place holds for me. I will provide them with the specific items I would like. I do not feel comfortable accessing the online catalog and/or do not have access to a computer or tablet. I would like them to select for me based on the criteria I will provide for them. How many items do you want to receive every two weeks? For example, 4 DVDs and 3 books.* Material Preferences (check all that apply):* Regular Print Large Print Paperbacks DVDs Audiobooks Music CDs Other If 'Other': Favorite Authors and/or Books and/or Movies:*Favorite Genres (Fiction, Mystery, Nonfiction, Travel, Science, etc.):*Home Delivery Helper PreferenceNote: If you have someone who can help serve as your volunteer (a friend, neighbor, or family member), we will contact you to get them set up in the system so they can check out materials for you. You will not need to be in the Words on Wheels Homebound Delivery Program and do not need to fill out any additional information. Home Delivery Helper Preference:* I have a friend, neighbor, or family member who I would like to serve as my volunteer. I would like the library staff to assign me a volunteer/staff member. Δ Share this:Click to print (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Twitter (Opens in new window)Click to share on Pinterest (Opens in new window)Click to email a link to a friend (Opens in new window)