Children's Museum of Cleveland

Children's Museum of Cleveland

MEMBERSHIP REQUEST FORM
Family Basic $100.00 (1 Adult and 1 Child living in the same household)

PLEASE NOTE: Additional family members may be added at a cost of $25 each. This cost is the responsibility of the family. Check with the facility for details. However, if there is more than one child/individual receiving funding through the Family Supports program, this cost will be covered by the Family Supports funding.
Cuyahoga DD Family Supports Program (FSP) Funding
Please choose a membership:*

$100 - Family Basic Membership for one adult and one child$175 - ACM Reciprocal Membership (Includes free admission to CMC for up to 4 individuals as well as half off admission at ACM reciprocal museums)
PLEASE NOTE: Additional family members may be added at a cost of $25 each. This cost is the responsibility of the family. Check with the facility for details.
INDIVIDUAL RECEIVING FAMILY SUPPORTS SERVICES:
First Name of Child/Individual*
Last Name of Child/Individual*
Date of Birth*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Are there other individuals in your household receiving FSP services?*

YesNo
Do you want to add them to the membership (additional $25 each will be deducted from Family Supports allocation)?*

YesNo
Are there other individuals in your household receiving FSP services?*

YesNo
Do you want to add them to the membership (additional $25 each will be deducted from Family Supports allocation)?*

YesNo
Please list all the FSP individuals you would like added to the membership. These individuals MUST be receiving FSP funding. Please also list the amount to be used towards their FSP allocation (if any).*
Please Choose a Membership Package*

Family Basic $80.00 (2-3 People living in same household)Family Plus $120.00 (4-6 People living in the same household) (please note, additional family member costs is the responsibility of the family)
PRIMARY ADULT MEMBER INFORMATION*

First Last
Gender*
Date of Birth*

MonthDayYear
Date
ADDITIONAL FAMILY MEMBER(S) (Limit of 2):*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone *
Is this phone number a cell or home
Additional Family Basic Member Information - (if applicable)
*

I understand that memberships are non-refundable and non-transferable
All other Family Member(s) to be added to the Membership*
Signature*

Clear
Submission Date*

YearMonthDay
Date
Note: Memberships are non-refundable and non-transferable
Should be Empty:

Children's Museum of Cleveland

Cuyahoga DD Family Supports Program (FSP) Funding

INDIVIDUAL RECEIVING FAMILY SUPPORTS SERVICES:

Additional Family Basic Member Information - (if applicable)

Note: Memberships are non-refundable and non-transferable