Lake Metroparks Farm Park
MEMBERSHIP APPLICATION
Cuyahoga DD Family Supports Program (FSP) Funding
Membership Includes:
Includes 2 adults living at the same address (both names must be on the card) or a single parent and one adult guest and up to 5 children younger than 18 years of age.
Individual Receiving FSP Services:
First Name of Child/Individual
*
Last Name of Child/Individual
*
Date of Birth
*
-
Month
-
Day
Year
Date
Please choose an annual membership:
*
Family: $75- Two adults living at the same address (both names must be on the card) or a single parent and one adult guest and up to five children (younger than 18 years)
Family + 2: $100- Same as Family, plus two additional guests on each visit
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.
*
ADULT(S) INFORMATION: (maximum of 2)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Telephone Number
*
Membership changes/cancellations:
*
I understand that once my membership has been purchased, I CANNOT change or cancel my membership request.
Signature
*
Clear
Submission Date
*
-
Year
-
Month
Day
Date
SUBMIT
Should be Empty: