The Cleveland Museum of Art
MEMBERSHIP REQUEST FORM
Cuyahoga DD Family Supports Program (FSP) Funding
INDIVIDUAL RECEIVING FSP SERVICES:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
-
Month
-
Day
Year
Are there other individuals in your household receiving FSP services?
*
Yes
No
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?
*
Yes
No
Please list all the FSP individuals whose FSP funding is to be used towards this membership, and the amount for each.
*
SELECT MEMBERSHIP:
*
PARTNER $90: Includes 2 adults (19+) and children (2-18) in the same household
AMBASSADOR $140: Members at the Ambassador level enjoy nationwide reciprocity with participating institutions with the benefits of membership for two adults and children.
SELECT MEMBERSHIP:
*
FRIEND $65: Includes 1 adult (19+) and children (2-18) in the same household
PARTNER $90: Includes 2 adults (19+) and children (2-18) in the same household
AMBASSADOR $140: Members at the Ambassador level enjoy nationwide reciprocity with participating institutions with the benefits of membership for two adults and children.
ADULT INFORMATION:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
*
E-mail
*
example@example.com
Signature
*
Clear
Submission Date
*
-
Year
-
Month
Day
Submit
Should be Empty: