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City of Euclid, Ohio

585 E 222nd St, Euclid, OH, United States

216-289-2700

Home
City Hall
City Departments
Residents
Recreation
Shore Cultural

Euclid Neighborhood Center Agency Referral Form

July 24, 2025

Community / Self Referral Form

Date of Referral:

Referrering Agency:

Referral Contact Name:

Referral Contact Title:

Referral Contact Phone Number:

Name:

Phone Number:

Street Address:

City:

Zip Code:

Last 4 Digits SSN:

Does the resident being connected currently have child(ren) under 18 years old?

YES

N/A

Is the resident being connected currently involved with DCFS?

YES

N/A

Is the resident being connected currently 65 or older?

YES

Household Member #1 Name:

Household Member #1 Date of Birth:

Household Member #1 Relationship:

Household Member #2 Name:

Household Member #2 Date of Birth:

Household Member #2 Relationship:

Household Member #3 Name:

Household Member #3 Date of Birth:

Household Member #3 Relationship:

Household Member #4 Name:

Household Member #4 Date of Birth:

Household Member #4 Relationship:

Household Member #5 Name:

Household Member #5 Date of Birth:

Household Member #5 Relationship:

Relationship to Child(ren):

Parent

Legal Guardian

Foster / Adoptive Parent

Other

Brief Statement of Need:

I acknowledge and understand that by submitting this referral form, I am providing the information to the Euclid Neighborhood Center and all affiliated entities as part of their effort to provide human services to the resident in need. I agree that all the information I have provided is accurate and truthful to the best of my knowledge.

YES

Thank you for contacting us.
We will get back to you as soon as possible.

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