Greater Cleveland Aquarium

Greater Cleveland Aquarium

FAMILY MEMBERSHIP REQUEST
Cuyahoga DD Family Supports Program (FSP) Funding
Individual Receiving FSP Services
First Name of Child/Individual*
Last Name of Child/Individual*
Date Of Birth*

MonthDayYear
Date
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
Please list all the FSP individuals whose FSP funding is to be used towards this membership, and the amount for each.*
FAMILY MEMBERSHIP:

Includes 2 adults (10+) and up to 6 children (2-18) in the same household
MEMBERSHIP TYPE (choose one):*

$130 - New Family Membership$117 - Renewal Family Membership
If Renewal, enter your membership id (begins with E): enter # here*.
ADULT(S) NAME (Maximum of 2):*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Number of Children in Family*
List all Children in Family for this Membership (maximum of 6)*
NOTE: If there are more than 6 children - the family is responsible for additional cost. They may be added on by the family, after purchase is made with the funding.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
E-mail*
example@example.com
Membership changes/cancellations:*

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

Clear
Signature Date*

YearMonthDay
Date
Should be Empty:

Cuyahoga DD Family Supports Program (FSP) Funding