This form will take approximately 15 minutes to complete. Please allow yourself enough time to complete this form in one session as there is not an option to save and come back to it later. The questions marked with an asterisk (*) are mandatory and require an answer. You do not have to answer all of the other questions, but it would help us if you do. This form asks for details about the person making the request and the person who will be using the item, which may be the same person. The information will be used to deliver the item/s to you and to help us monitor how useful different items are for different groups of people. We may report numbers of requests and loans of different items to different groups, such as children, but we will not use any personal information for anything other than supplying your loan. Tell us about you Title Select your title. Mr Mrs Miss Ms Dr Other Other Enter your title if not listed above. First name Enter your first name. Last name Enter your last name. Email address Enter an email address where we can write to you. Library card number * Enter the 9-digit number found on the back of your library card. Phone number Enter a daytime phone number that we can ring you on. This can be a mobile or land line number. Who is your enquiry about? Select a relevant option. I am an adult enquiring for myself I am a friend/relative of an adult I am a practitioner working with adults I am a parent/carer of child/young person I am a practitioner working with child/young person Other (please explain) Other Enter who your enquiry is about. What item/s would you like to borrow? * Enter the item/s description, which can be found in the 'Communication library catalogue'. What is the item/s reference? Enter the item/s reference, which can be found in the 'Communication library catalogue'. Which local library would you like to collect the item from? * Select the library of your choice. Angmering Library Arundel Library Billingshurst Library Bognor Regis Library Broadfield Library Broadwater Library Burgess Hill Library Chichester Library Community Mobile 1 (Bognor) Community Mobile 2 (Horsham) Crawley Library Durrington Library East Grinstead Library East Preston Library Ferring Library Findon Valley Library Goring Library Hassocks Library Haywards Heath Library Henfield Library Horsham Library Hurstpierpoint Library Lancing Library Littlehampton Library Midhurst Library Petworth Library Pulborough Library Rustington Library Selsey Library Shoreham Library Southbourne Library Southwater Library Southwick Library Steyning Library Storrington Library Willowhale Library Witterings Library Worthing Library Can we contact you by email to find out how it helped you and the person using it? Select an option. Yes No Tell us about the person who will use the item First name Enter their first name. Last name Enter their last name. Age Enter person's age or your age in years. Do you or this person have any disabilities or health conditions? Select an option. Yes No Details Enter details of any disabilities or health conditions. How will this item help? Enter details below. Are you or this person being supported by any health service teams, for example speech therapy? Select an option. Yes No Details Enter details of any health service teams. Do you have anything else you want to tell us about your request? Select an option. Yes No Details Enter any other details about your request. Submitting your form Click the submit button only once. Please be patient as it will take a few moments to process your form and redirect you to our confirmation page.