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
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)
Select Annual Membership Level (See details of each membership below):
*
$99 DUO (Adult OR Adult + 1 Child)
$149 DUO+ (Adult OR Adult + 1 Child)
$179 PACK (2 Adults + 6 Children)
$269 PACK+ (2 Adults + 6 Children)
$499 PREMIUM (2 Adults + 6 Children)
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)
Primary Adult Member's Information:
Adult
*
First Name
Last Name
Telephone Number
*
E-mail
*
PLEASE ENTER A VALID EMAIL - A PURCHASE CONFIRMATION WILL BE SENT TO THIS EMAIL ADDRESS
Address
*
Street Address
City
State / Province
Postal / Zip Code
Additional Family Member
*
Additional Adult Family Member to be included on the membership (if applicable)
Additional Adult Family Member to be included on the membership (if applicable)
First Name
Last Name
Number of Children
*
Membership changes/cancellations:
*
I understand that once my membership has been purchased, I CANNOT change or cancel my membership request. I also understand that the prices listed are not guaranteed and are subject to change at any time.
Signature
*
Submission Date
*
-
Year
-
Month
Day
Date
Submit
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