Cleveland Museum of Natural History
MEMBERSHIP REQUEST FORM
Cuyahoga DD Family Supports Program (FSP) Funding
INDIVIDUAL RECEIVING FSP SERVICES:
First Name
*
Last Name
*
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
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 Annual Membership Level (Cost includes $5 for membership cards)
*
$85 MANTIS: 2 Adults OR 1 adult + Child (includes 4 guest passes per year)
$105 RIVER: 2 Adults + Children (includes 6 guest passes per year)
$155 PACK: 2 Adults + Children + Caregiver (includes 2 guest passes per visit)
Select Annual Membership Level (Cost includes $5 for membership cards)
*
$85 MANTIS: 2 Adults OR 1 adult + Child (includes 4 guest passes per year)
$105 PACK: 2 Adults + Children + Caregiver (includes 2 guest passes per visit)
Select Annual Membership Level (Cost includes $5 for membership cards):
*
$75 GEMSTONE: 1 Adult (includes 2 guest passes per year)
$85 MANTIS: 2 Adults OR 1 adult + Child (includes 4 guest passes per year)
$105 PACK: 2 Adults + Children + Caregiver (includes 2 guest passes per visit)
Primary Adult Member's Information:
Adult
*
First Name
Last Name
Telephone Number
*
E-mail
*
example@example.com
Address
*
Street Address
City
State / Province
Postal / Zip Code
Additional Family Member
*
Additional Adult Family Member to be included on the membership (if applicable)
Name
First Name
Last Name
Number of Children
*
Signature
*
Clear
Submission Date
*
-
Year
-
Month
Day
Date
Submit
Should be Empty: