Outreach Senior Facility Form

Senior Facility Name*

Invalid Input. Please enter the facility's name.

Senior Facility Address*

Invalid Input. Please enter your address in the 12345 Main Street format.

Activities Director/Contact Name*

Invalid Input. Please enter the director's name.

Facility Phone Number*

Invalid Input. Please enter the facility's number as (804-123-4567).

Email address*

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Estimated number of facility residents to be served by Mobile Library*

Invalid Input. Please enter only digits in this field.

Does your facility have enough room for a 29 foot van to maneuver, unload/load book carts, and park?*

YesNo Invalid Input. Please make a selection.

Does your facility have a community space large enough to accomodate 6 large book carts (2'x3'), with room for your residents to browse them comfortably regardless of ambulatory restrictions?*

Yes

No

Perhaps, if we could have less carts

Invalid Input. Please select an answer.

This application is an indicator that you are interested in receiving visits to your facility from the Mobile Library Service. It does not guarantee that this service will be available to your location at this time. Upon receipt of the application, a staff member will be in contact with you to discuss your service options.*

 I agree

 I disagree

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Spam Prevention*

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