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 choose a membership:*

$100 - Family Membership for one adult and one child$125 - 3 people Family Membership$150 - 4 people Family Membership$175 - 5 people Family Membership
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 the cost of this membership to be split up amongst multiple individuals receiving FSP services?*

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 individuals whose FSP funding is to be used towards this membership, and the amount or percentage for each.*
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 (if splitting the membership between another FSP participant, list their name again here):*
ADDITIONAL FAMILY MEMBERS - if splitting the membership between another FSP participant, list their name(s) again here. (LIMIT OF 2 - Total # of people cannot exceed 4):*
ADDITIONAL FAMILY MEMBERS - if splitting the membership between another FSP participant, list their name(s) again here. (LIMIT OF 3 - Total # of people cannot exceed 5):*
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)
Membership changes/cancellations:*

I understand that once my membership has been purchased, I CANNOT change or cancel my membership request.
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