2024 Recreation Request Form

2024 - Recreation Request Form

Cuyahoga DD Family Supports Program (FSP) Funding
Cuyahoga DD Family Supports Program recreation service provides funding to allow individuals to participate in activities of interest in their local community. We consider Northeast Ohio to be within the local community of the individuals we serve.

Counties included in Northeast Ohio include:

Ashland, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, Medina, Portage, Richland, Stark, Summit, Tuscarawas, Wayne
You can find and complete the most frequently requested membership applications on NEON's website. Please click here to view those applications before proceeding with this request. Cuyahoga County is listed first. Scroll down and click on “RECREATION” and then scroll down to "Membership Applications".
Please note: If your request is for a Recreation Center membership at The City of Westlake, they are no longer acceping requests for 2024.
Please click here to see if the facility you are interested in is listed on our Frequently Requested Vendor Listing
Is the facility/vendor you are interested in located on the Frequently Requested Vendor Listing above?*

YesNo (Please note that this request may require additional processing time)
Individual Receiving FSP Services:
First Name of Child/Individual*
Last Name of Child/Individual*
Child/Individual Date of Birth*

MonthDayYear
Date
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*

Confirmation EmailPLEASE ENTER A VALID EMAIL
Telephone Number*
What County is the facility located in? (Facility must be located in one of these OHIO counties):*

CUYAHOGAAshlandErieGeaugaHuronLakeLorainMedinaPortageRichlandStarkSummitTuscarawasWayne
What is the name of the facility you are interested in?*
Facility Phone Number *
Please enter a valid phone number.
Total approximate cost of membership/activity:*
Facility Website link:*
Enter the link to the facility (copy and paste) - A website is required to assist with more timely processing. If the facility does not have a website, enter the following: https://neoncog.org/
Facility Address:

Street Address

CityState

Zip Code
Facility Contact Person:

First NameLast Name
Please provide details of the membership or activity your are interested in. Include as much detail as possible. For example, dates of lessons, descriptions of the lessons, type of membership, length of membership, etc.:*
I understand that this is an established Cuyahoga DD/NEON vendor, and I am to contact the facility directly for assistance with enrollment. It is my responsibility to verify my available Family Supports funding balance before reaching out to vendors, granting them permission to utilize my Family Supports funding to cover this activity.
I understand that it is my responsibility to verify my available Family Supports funding balance before reaching out to vendors, granting them permission to utilize my Family Supports funding.
I understand that it is my responsibility to verify my available Family Supports funding balance, and I will be utilizing this funding to cover this activity.
I give permission for Neon to share details about this FSP funding request with the vendor listed on this form. I agree to follow the policies of this vendor, including vendor pricing, cancellation policies, and other possible requirements
Signature*

Clear
Submission Date*

YearMonthDay
Date
Should be Empty:

2024 - Recreation Request Form

Individual Receiving FSP Services: