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Pre-Admission Application

Gender *

Male

Female

Other

*

Select an option *

I have health insurance

I do not have health insurance

I am unsure of my health insurance status

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Are you a registered sex offender? *

Yes

No

Are you a registered arsonist? *

Yes

No

By checking this box I am confirming that I have personally completed the information above correctly and truthfully. I understand that any false information may result in losing my residency.

THANK YOU FOR SUMBITTING!

A STAFF MEMBER WILL CALL ASAP!

HOURS:

M - F: 9AM – 4PM

SAT & SUN: CLOSED

ADDRESS:

3222 North Ridge Rd.

Elyria, OH 44035

PHONE & EMAIL:

(440) 219-4774

admin@primarypurposecenter.com

Primary Purpose Center is a non-profit organization, and is exempt from taxation under Section 501(c)(3) of the U.S. tax code. Contributions by U.S. taxpayers are deductible to the extent permitted by law.

PROGRAM GENEROUSLY SUPPORTED BY:

Drop-Offs are ONLY during OFFICE Hours: Monday - Friday 9:00am - 2:00pm - NO EXCEPTIONS

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