HomeConnect Application

HomeConnect Service Application
First*
Middle
Last*
Preferred Name optional
Date of Birth MMDDYYYY*

MonthDayYear
Date
Name of Facility if any
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone*
Library Card Number
If you do not have a library card, we will issue one and mail it to you.
Secondary Contact

(Authorize to discuss this account)
Name
Relationship
Phone
Email
example@example.com
Are you eligible to participate under the USPS program “Free Matter for the Blind”

Yes
I affirm that I am unable to travel to the Johnson County Library due to lack of transportation, disability, or injury.*

Yes
Home Connect Use Agreement - Please read and sign below

I apply for the privilege of borrowing library materials from the Johnson County Library HomeConnect Service. I give permission for library staff to use my card number to check out materials on my behalf. I agree that a record of my interests and check out history may be kept, with the understanding that my check out history and interests will be kept confidential. I agree to be responsible for all materials checked out to this card, and for replacement costs of any lost or damaged materials. I declare that I am homebound and unable to come to the library.
Signature*

Clear
Date*

MonthDayYear
Date
We'll send a letter to confirm we've received your application. Questions? You can reach us by phone at (913) 826-4600.
Email
example@example.com
Should be Empty:

HomeConnect Service Application