Great Lakes Science Center

Great Lakes Science Center

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

YearMonthDay
Date
Date of Birth*

MonthDayYear
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.
For more detailed information on the membership levels, please click here: Great Lake Science Center Website. The website will open in a new window.
PLEASE CHOOSE A MEMBERSHIP LEVEL:

$75.00 per Individual - 1 named adult member$99.00 per Individual MAX - 1 named adult and 1 guest$139.00 per Family - Up to 2 named adults and up to 6 minor children in the same household$169.00 per Family PLUS - Up to 2 named adults and up to 6 minor children in the same household + 2 guests$199.00 per Family MAX - Up to 2 named adults and up to 6 minor children in the same household + 2 guests
MEMBERSHIP LEVEL (Choose one. See chart below for level details):*

$ 75 - Individual$ 99 - Individual Max$139 - Family$169 - Family Plus$199 - Family Max
Adult 1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Telephone Number*
Adult 2

First NameLast Name
Number of Children for Membership
Signature*

Clear
Signature Date*

YearMonthDay
Date
Should be Empty:

Great Lakes Science Center

Cuyahoga DD Family Supports Program (FSP) Funding

Individual Receiving FSP Services: