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Books+ Express Client Intake Form
Books+ Express Client Intake Form
Part I: Personal Information
Name
If you are registering on someone else's behalf, please enter your name here (ex. you are a staff member or family member)
First
Last
Client's Name
(Required)
First
Last
Library Card Number
Please do not include spaces in your barcode number.
Birthdate
Month
Day
Year
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Buzzer Number (if applicable)
Email Address
Phone Number
Preferred Method of Contact
Phone
Email
Other
Please briefly share why you are interested in the Books+ Express Service.
Do you give your permission for the Pickering Public Library to disclose your phone number and address as recorded in this intake form, to a volunteer selected by the library, for the purposes of the volunteer to pick up/drop off materials at your home?
(Required)
Yes, and I am filling this form out for myself, and acknowledge that checking off this option acts as my consent to disclose my personal information to the volunteer selected by the library.
Yes, and I consent to signing the disclosure form during the volunteer's first visit to my home.
No, I would prefer the library mail me the disclosure form and I will sign it and pay for the return postage to mail the form back to the library.
Other
(OPTIONAL) Do you give permission for the Pickering Public Library to disclose and/or change information on your library account (address, phone number etc.) that is provided by your emergency contact listed below. (Please include their name, phone number, email address, and relationship to you)
Please indicate the approximate days and times you would prefer for items to be dropped off/picked up at your home below:
Monday:
Morning
Afternoon
Evening
Any time during the day
Tuesday:
Morning
Afternoon
Evening
Any time during the day
Wednesday:
Morning
Afternoon
Evening
Any time during the day
Thursday:
Morning
Afternoon
Evening
Any time during the day
Friday:
Morning
Afternoon
Evening
Any time during the day
Saturday:
Morning
Afternoon
Evening
Any time during the day
Sunday:
Morning
Afternoon
Evening
Any time during the day
To deliver items to your home, will the Library volunteer need to:
Walk up more than 5 stairs
Use an elevator
Neither
Do you have any pets?
(Required)
Yes
No
Pet Details
How many items would you like to receive during each visit?
Do you currently place items on hold?
Yes
No
Would you be interested in learning how to place items on hold?
Yes
No
Is there anything else the Library volunteer should know before delivering library items to your home?
Part II: Format of Materials
Please indicate your preferred format for the materials that are delivered to your home.
Print Materials
Hardcover
Paperback
Large Print
Regular Print
Braille
Graphic Novels
Magazines
Audiobooks
Audiobooks on MP3 CDs
Audiobook CDs
DAISY
Preferred Language for Materials:
Part III: Content Preferences
Please indicate your preferred content preferences for the materials that are delivered to your home.
What is the audience for the materials you are looking for?
Adult
Young Adult
Children
Would you like Non-Fiction books/audiobooks delivered?
Yes
No
Preferred Non-Fiction Genres
Select all that apply.
Biography or Memoirs
Cooking
Crafts
Current Events
Entertaining Non-Fiction
Essays
History
Home and Garden
Humour
Indigenous
Language
LGBTQIA+
Mind and Body
Exercise
Health/Medicine
Music
Nature
Parenting and Families
Poetry
Politics
Psychology
Religion and Spirituality
Royalty
Science
Social Sciences
Sports
Technology
Travel
True Crime
War
Other
Would you like Fiction books/audiobooks delivered?
Yes
No
Preferred Fiction Genres
Action and Adventure
Animals
Bestsellers
Coming of Age
Contemporary Fiction
Christian/Inspirational
Family Relationships
Fantasy
Folklore/Fairytales
Historical Fiction
Horror
Indigenous
LGBTQIA+
Literary Fiction
Mystery
Cozy Mysteries
Detective Mysteries
Graphic Mysteries
Historical Mysteries
Romance
Cozy Romance
Paranormal Romance
Risque Romance
Science Fiction
Short Stories
Thriller and Suspense
Domestic Thriller/Suspense
Psychological Thriller/Suspense
Spy Thriller/Suspense
Westerns
Other
Select all that apply.
Would you like movies delivered?
Yes
No
Preferred movie genres
Action
Adventure
Comedy
Crime and Mystery
Fantasy
Historical Fiction
Horror
Thriller
Romance
Science Fiction
Western
Documentaries
Non-Fiction
Performing Arts
World Cinema
Other
Would you like television shows delivered?
Yes
No
Preferred television genres
Action and Adventure
Animation
Comedy
Crime and Mystery
Documentaries
Drama
Historical
Horror
Performing Arts
Science Fiction
Western
Other
Would you like music CDs delivered?
Yes
No
Preferred music genres
Classical
Contemporary
Country and Western
Folk and Gospel
Jazz and Blues
Musicals and Soundtracks
Opera
Popular
Rap and Hip Hop
Recent Releases
World Music
Other
If there are any other details we should know that have not been addressed in the form please enter those details below (e.g. certain authors you do or do not like? Your CELA number if you have one):
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