Holden Arboretum and Botanical Gardens
MEMBERSHIP REQUEST FORM
Cuyahoga DD Family Supports Program (FSP) Funding
Individual receiving FSP services:
First Name of Child/Individual
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Last Name of Child/Individual
*
Date of Birth
*
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Month
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Day
Year
Date
Birthdate:
*
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Year
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Month
Day
Date
SELECT MEMBERSHIP LEVEL:
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HF&G2 ($85) = Includes 1-2 named members (number of people admitted = 2)
HF&G4 ($115) = Includes 1-2 named members (number of people admitted = 4)
HF&G6 ($170) = Includes 1-2 named members (number of people admitted = 6)
Are there other individuals in your household receiving FSP services?
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Yes
No
Do you want the cost of this membership to be split up amongst multiple individuals receiving FSP services?
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Yes
No
Please list all the FSP individuals whose FSP funding is to be used towards this membership, and the amount for each.
*
ADULT 1 - PRIMARY MEMBER:
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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
Street Address Line 2
City
State / Province
Postal / Zip Code
ADULT 2:
First Name
Last Name
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
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Submission Date
*
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Year
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Month
Day
Date
Submit
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