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2. Enter the information for the primary Home Delivery Program user here:
4. Name*
6. Phone Number*
7. Library Card Number*
9. Email Address*
10. The best way to contact me is:*

    1. By Email
    2. By Phone
12. Emergency Contact
14. Name*
15. Relationship*
17. Emergency Contact's Phone Number*
18. Emergency contact's email address:
20. Is your emergency contact authorized to receive information about your library account if needed?

    1. Yes
    2. No
22. Acknowledgement of program eligibility: Individuals who live in the Town of Clayton and Town of Clayton ETJ, are library cardholders in good standing, and are unable to get to the library because of age, disability, illness, and/or the coronavirus public health crisis are eligible to participate in this program.
24. Please check all that apply to you.

    1. I live in the Town of Clayton or the Clayton ETJ.
    2. I am a cardholder in good standing.
    3. I am unable to get to the library because of an age-related / illness / disability reason.
    4. During the COVID-19 health crisis I am unable to leave my house for non-essential trips.
    5. Other
26. Other

    If you selected other please provide more information.

28. Home Delivery Program Information

    Patrons are asked to select their own materials using the library's online catalog or, if this is not possible, by calling a library staff member for assistance during library hours.

30. Check the box that most closely explains your selection abilities:*

    1. I am able to use the library's online catalog to select materials and put materials on hold.
    2. I would like to receive training to learn how to use the library's catalog to select materials and put the on hold. I have a computer or tablet.
    3. I do not feel comfortable using the online catalog and will need staff assistance to choose books and place holds.
32. Indicate your preferred format (check all that apply).

    1. Physical Book
    2. Large Print Book
    3. Book on CD
    4. e-Book
    5. e-Audiobook
    6. Other
34. Other

    If you selected other please provide more information.

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field