Download a Home Library Service Application form ... - Libraries ACT
Download a Home Library Service Application form ... - Libraries ACT
Download a Home Library Service Application form ... - Libraries ACT
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APPLICATION FOR HOME LIBRARY SERVICE<br />
I wish to apply for membership of the <strong>Home</strong> <strong>Library</strong> <strong>Service</strong> provided by <strong>Libraries</strong> <strong>ACT</strong>. Due to<br />
age, a disability of a medical condition, I am unable to come to the library and/or cannot carry<br />
books home. I agree to con<strong>form</strong> to the conditions laid down by the library, and to pay any<br />
charges incurred for lost of damaged material.<br />
I understand that the library will ring me so that arrangements can be made, and that any<br />
personal in<strong>form</strong>ation I give to the library will be kept strictly private.<br />
<strong>Libraries</strong> <strong>ACT</strong> Conditions of Membership<br />
I apply for membership of <strong>Libraries</strong> <strong>ACT</strong> for myself/ my child.<br />
I agree to:<br />
Return library material by the due date<br />
In<strong>form</strong> the library of changes to my personal details<br />
Pay for lost, damaged or stolen library materials plus any administrative fees<br />
Pay any overdue fees charged<br />
Be responsible for ALL items borrowed on my or my child’s card<br />
I am aware that<br />
My membership will be suspended if there are excessive overdue fees of I have items<br />
overdue for fourteen days or more<br />
It is the responsibility of parent/guardians, not library staff, to determine what<br />
materials are suitable for my child/ren to borrow from the library and what my<br />
child/ren access on the Internet<br />
Having read the conditions, I agree to con<strong>form</strong> to them.<br />
Full name<br />
Date of birth<br />
Address<br />
Suburb<br />
Phone (home)<br />
Email<br />
Signature<br />
______________________________________<br />
______________________________________<br />
______________________________________<br />
____________________ Postcode __________<br />
________________ (mobile) _______________<br />
______________________________________<br />
____________________ Date _____________<br />
See page 2 for referral details – both <strong>form</strong>s must be completed and returned to the library.
Reasons for application (tick one)<br />
<br />
<br />
<br />
A short term illness, e.g. recuperating after an operation or suffering from a<br />
broken bone. Approximate time service will be required<br />
________________________________________________________<br />
Chronic or serious illness or disability that prevents me from visiting a library.<br />
Other (please specify) ______________________________________<br />
REFERRAL<br />
I nominate ______________________________ as a person requiring the<br />
services of the <strong>Home</strong> <strong>Library</strong> <strong>Service</strong> for reason/s listed above.<br />
Practitioner’s name<br />
______________________________________<br />
Organisation/occupation ______________________________________<br />
Address<br />
Suburb<br />
Phone (work)<br />
Email<br />
Signature<br />
______________________________________<br />
____________________ Postcode __________<br />
______________________________________<br />
______________________________________<br />
____________________ Date _____________<br />
<br />
<br />
Persons able to sign referral: Medical practitioner, activities officer (nursing homes),<br />
community nurse, community carer, Canberra Blind Society.<br />
A phone referral to 6207 5748 from one of the above is also acceptable.<br />
Please return <strong>form</strong>s to:<br />
MAIL<br />
<strong>Home</strong> <strong>Library</strong> <strong>Service</strong><br />
c/- Belconnen <strong>Library</strong><br />
12 Chandler Street<br />
Belconnen <strong>ACT</strong> 2617<br />
FAX<br />
6207 7400<br />
EMAIL<br />
(scanned completed <strong>form</strong>)<br />
library.customerinfo@act.gov.au
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