Holden Arboretum and Botanical Gardens
MEMBERSHIP REQUEST FORM
Cuyahoga DD Family Supports Program (FSP) Funding
Individual receiving FSP services:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
-
Month
-
Day
Year
Date
Birthdate:
*
-
Year
-
Month
Day
Date
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 MEMBERSHIP LEVEL:
*
HF&G2 ($80) = Includes 1-2 named members (number of people admitted = 2)
HF&G4 ($100) = Includes 1-2 named members (number of people admitted = 4)
HF&G6 ($160) = Includes 1-2 named members (number of people admitted = 6)
ADULT 1 - PRIMARY MEMBER:
*
First Name
Last Name
Telephone Number
*
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ADULT 2:
First Name
Last Name
Signature
*
Clear
Submission Date
*
-
Year
-
Month
Day
Date
Submit
Should be Empty: