Akron Children's Museum
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
*
-
Month
-
Day
Year
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 individuals whose FSP funding is to be used towards this membership, and the amount for each.
*
Select Annual Membership Level:
*
$ 65 - LEVEL 1: Up to 3 named individuals
$ 77 - LEVEL 1 PLUS: 4 named individuals
$ 90 - LEVEL 2: Up to 5 named individuals
$102 - LEVEL 2 PLUS: 6 named individuals
$150 - LEVEL 3: Up to 8 named individuals
$162 - LEVEL 3 PLUS: 9 named individuals
Primary Adult Family Member:
*
First Name
Last Name
Address
*
Street Address (Include Apt #, Up/Down, etc)
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE NUMBER:
*
Please enter a valid phone number.
E-MAIL:
*
example@example.com
SIGNATURE:
*
Clear
SUBMISSION DATE:
*
-
Year
-
Month
Day
Submit
Should be Empty: